THIRTIETH MEETING

THE PRESIDENT\'S COUNCIL ON BIOETHICS

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THURSDAY

SEPTEMBER 6, 2007

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The Council met at the Carolina Inn, 211 Pittsboro Street, Chapel Hill,
North Carolina, Chairman Edmund D. Pellegrino, presiding.

[COUNCIL MEMBERS PRESENT]{.underline}:

[Edmund D. Pellegrino, M.D.,
Chairman](http://www.bioethics.gov/about/members.html)

Floyd E. Bloom. M.D.**\
**[Benjamin S. Carson, Sr., M.D.**\
**](http://www.bioethics.gov/about/carson.html)[Rebecca S. Dresser,
J.D.](http://www.bioethics.gov/about/dresser.html)**\
**[Daniel W. Foster,
M.D.](http://www.bioethics.gov/about/foster.html)**\
**[Robert P. George, D.Phil.,
J.D.](http://www.bioethics.gov/about/george.html)**\
**[Alfonso Gómez-Lobo,
Dr.phil.](http://www.bioethics.gov/about/gomezlobo.html)**\
**[William B. Hurlbut,
M.D.](http://www.bioethics.gov/about/hurlbut.html)**\
**[Leon R. Kass, M.D.](http://www.bioethics.gov/about/kass.html)**\
**Peter A. Lawler, Ph.D.

Gilbert C. Meilaender, Ph.D.

Janet D. Rowley, M.D.

Diana J. Schaub, Ph.D.

Carl E. Schneider, J.D.

[CONTENTS]{.underline}

Introduction, Chairman Pellegrino \...\...\...\...\...\.... 3

Session 1. The Draft White Paper on the

Determination of Death

Comment by Dr. Diana J. Schaub, Ph.D. \...\...\... 5

Discussion by Council Members\...\...\...\...\..... 13

Session 2: The \"Crisis\" in the Ethics and Profession of Medicine: A
Historical Perspective

David Rothman, Ph.D. \...\...\...\...\...\...\...\.... 58

Comment by Daniel W. Foster, M.D\...\...\...\..... 86

Discussion by Council Members\...\...\...\...\..... 96

Session 3: The \"Crisis\" in the Ethics and Profession of Medicine: The
Perspective of Medical Education

Jordan Cohen, M.D. \...\...\...\...\...\...\...\..... 126

David Leach, M.D. \...\...\...\...\...\...\...\...\... 159

Session 4: The \"Crisis\" in the Ethics and Profession of Medicine: Some
Concluding Reflections

Edmund D. Pellegrino, M.D. \...\...\...\...\...\... 220

Adjourn

[PROCEEDINGS]{.underline} 9:02 a.m.

CHAIRMAN PELLEGRINO: Good morning. Good morning. Welcome to the meeting
of the President\'s Council.

The first act in these meetings always is for the chairman to recognize
the presence of the official government representative who sits to my
left, Dr. Daniel Davis, who is the Executive Director of the Council.
Dan, we acknowledge your presence and are delighted to have you as
always. Dan is the man who does all the work on the Council. You must
know that. It\'s not just a title that he carries.

I would like to begin this Council meeting by expressing on my behalf
and on behalf of the members of the Council our gratitude to Dr. Leon
Kass who has completed his current course of appointment and has asked
to resign from the Council.

It\'s my great pleasure to personally enter into the record, I hope
adequately, the gratitude of the members of this Council to Leon, who
really is the founder of the Council, the first chairman, its
inspiration, and a person who has set a very high standard for the work
of the Council and whom I\'ve had the pleasure of knowing as a colleague
for many, many years. Leon, we thank you most sincerely.

Leon is serving on the Council beyond his previous termination of term
at my request, and I had hoped that he would continue. But his own
personal preference is now to direct his attention to many, many of the
other things which he\'s doing. We understand that.

But he has promised me to be available to us. And those of you who know
him, know him as a source of wisdom that we did not want to lose any
contact with, both personally and also, of course, officially as the
Chairman of the Council.

So, Leon, thank you most sincerely. And if I can break precedent, I\'d
like to.

*(Applause.)*

This is one time, Leon, you don\'t have to respond. I\'m sure Leon
suspects, \"Oh, there he goes,\" and he doesn\'t want us to say too much
--- not the case.

Our agenda this morning, or today rather, covers the following two
topics: The determination of death, which has come to be a very actively
discussed issue now that had been closed for many years or assumed to be
closed; and then the latter part of the day some discussions of the
status and the question of professionalism in medicine and the other
health professions and, to a more distant degree, those other
professions outside of the health field. Tomorrow, we will look once
again and be brought up-to-date on the status of nanotechnology and the
ethics associated with it.

I would like to begin the first presentation. Diana Schaub, a member of
the Council, who will initiate an open discussion, has kindly consented
to do so on the staff paper prepared by Dr. Alan Rubinstein. Dr. Schaub?

PROF. SCHAUB: As some of you know, I\'m a fan of the original *Star
Trek* series, and I remain unabashedly a fan despite the teasing that
such a declaration can bring.

The best known line from *Star Trek* must be \"Beam me up, Scotty,\" but
a close second would be \"He\'s dead, Jim.\" In episode after episode,
Dr. McCoy arrives to examine a prone crew member. He waves a wand-like
instrument over him, then looks at Captain Kirk, and says \"He\'s dead,
Jim.\"

I think that\'s how we want the determination of death to go. We don\'t
want folks to die, but if they\'re going to, we want a clear
pronouncement. not \"Well, he\'s dead by Criteria Set 4, but still alive
by Criteria Set 2.\"

Now we are never told what precisely Dr. McCoy\'s tricorder registers,
but perhaps it takes the measure of the three body systems that this
report focuses on: The heart and circulatory system; the lungs and
respiratory system; and the central nervous system, and, in particular,
the centers involved in breathing.

The fact that he uses a medical device of some kind does suggest that
his verdict, while stated apodictically may, in fact, be based on
evidence that is harder to discern and more ambiguous.

We\'ve long known that there can be ambiguity surrounding death. There
can be illnesses and conditions that mimic death. Think of all those
folks unfortunately buried alive in the stories of Edgar Allen Poe.
There are also drugs and potions that can deliberately mimic death.
Think of the friar\'s description in Romeo and Juliet:

Take thou this vial, being then in bed,

And this distilling liquor drink thou off;

When presently through all thy veins shall

run

A cold and drowsy humor; for no pulse

Shall keep his native progress, but

surcease;

No warmth, no breath, shall testify thou

livest;

The roses in thy lips and cheeks shall fade

To wanny ashes, thy eyes\' windows fall

Like death when he shuts up the day of life;

Each part, deprived of supple government,

Shall, stiff and shark and cold, appear like

death;

And in this borrowed likeness of shrunk

death

Thou shalt continue two-and-forty hours,

And then awake as from a pleasant sleep.

Interestingly, Shakespeare mentions three tests: the pulse, the breath,
and the \"eyes\' windows.\" The three seem to roughly match our existing
standards for a determination of death: the cessation of circulatory
function, the cessation of respiratory function, and total brain
dysfunction.

I suppose it would be too much to ask doctors to use Shakespeare\'s more
mellifluous language, but it is a remarkably clear set of bedside tests:
\"no pulse shall keep his native progress,\" \"no warmth, no breath
shall testify thou livest,\" and, last, the \"eyes\' windows fall.\"

In the past, it seems that what was likely to be obscured and hidden
from view was the presence of life. We could be fooled by the outward
appearance of death and overhasty in consigning the living to the places
of the dead.

With the advent of life-prolonging technologies, particularly the
mechanical ventilator, there is a new twist on the old ambiguities and
mistakes. A device meant to save life may, we are told in certain
situations, only mimic or simulate life. We have been assured that death
may, in fact, occur, despite some of the signs and likeness of life
continuing as a result of medical artifice. So what is obscured and
hidden from view now is the presence of death.

That itself is progress. It\'s surely better for death to be disguised
or unperceived because of the work of a ventilator than for life to be
disguised or missed because of a mistaken judgment. Not nearly as much
harm is done when we err on the side of life.

This report, \"Controversies in the Determination of Death,\" does a
fine job of setting forth the evolution of thinking about the standards
for determining death. It traces the emergence of an alternative
neurological standard of death in the 1970s to supplement the
traditional cardiopulmonary standard and examines the continuing
challenges to that standard.

It turns out there are some overlaps between our work on this issue and
our work on organ transplantation. There is a hint that transplant
politics may have played a role in the pressure to formulate and adopt
the neurological standard of death, just as it is playing a role now in
the pressure to make certain alterations in the neurological standard,
moving from a strict whole brain focus to a looser consciousness-related
formulation.

While I find this linkage disturbing --- and I confess it makes me
inclined to be a bit suspicious of the neurological standard --- I also
believe that it\'s best to assume good will on all sides in scientific,
intellectual, and even political debate.

Even if the neurological standard was in part motivated by a desire to
create the heart-beating dead-donor category, the question still
remains: Is the category a true one? Are there heart-beating cadavers
and ventilated corpses such that we need a neurological basis for the
determination of death?

Admirably, the report takes up this question in Chapter 4, first laying
out the reasons for doubt that were posed originally by Hans Jonas and
elaborated and updated more recently by Shewmon and then, most
ambitiously, attempting to answer those doubts and defend the
neurological standard with a new and better biologically-based
rationale.

The debate concerns the meaning of wholeness. Instead of looking
internally at the presence or loss of somatic integration, the report
suggests that we look at the organism\'s relation to the external world.
A living organism is in need of and open to commerce and exchange with
its environment. Spontaneous breathing is a crucial manifestation of
such openness.

The report even states that this \"commerce with the surrounding world\"
is \"the definitive \'work\' of an organism.\" When the drive for such
commerce is irreversibly gone, as in total brain dysfunction, then the
individual is dead.

I don\'t know quite what to make of this argument. To a political
scientist, used to thinking more about the body politic than the
individual body, it\'s certainly intriguing. According to Aristotle, the
wholeness of a body politic is a matter of internal structure,
integrated functioning, and purpose. It\'s more about domestic politics
than about foreign relations or commerce with the world.

This difference in self-sufficiency between bodies politic and
individual bodies may just be a sign that the analogy is flawed and that
bodies politic are not living organisms. Still, it seems to me odd to
say that the wholeness of a living organism hinges on its needy
openness. Apparently the wholeness of organic life is not whole in the
sense of complete or unified.

But even granting that organisms have a needy, outward-directed mode of
being, is it correct to say that satisfying this need is the definitive
work of an organism? Isn\'t it just a precondition of the real work? If
that precondition is met by artificial means, like a ventilator, some at
least of that internal work of the organism continues. Would the fact
that the body uses the supplied oxygen be an indication that the drive
for breath is present internally, even if it\'s not capable of
independent external operation?

Most astonishing, I thought, were the cases of pregnant women diagnosed
with total brain dysfunction whose bodies continued to provide support
to the developing fetus for days and even months.

My uncertainty about the line between life and death would, I think,
have inclined me to resist the neurological standard back in the 1970s.
However, that same uncertainty leaves me inclined today to accept the
settled, majority view of the medical profession.

Nonetheless, the debate seems to me salutary. Openness to new evidence
and arguments is as much a part of the scientific enterprise as
spontaneous breathing is to the living organism.

CHAIRMAN PELLEGRINO: Thank you very much, Dr. Schaub, for opening up the
discussion leading us into a number of serious issues and questions. I
really appreciate it and thank you.

Dr. Schaub\'s comments and the staff paper itself are now open to
discussion by members of the Council. Does anyone wish to --- Dr. Bloom?

DR. BLOOM: I sent these comments to Alan. It seems to me that there are
three general points.

This draft is much better to me than was the original, but I think we go
still too far overboard in paying attention to the objections of Shewmon
over and over and over again. It seems to me that confronting his issues
and then rebutting them is sufficient. But we go through it in almost
every chapter, and it seems to me to give more credence than that set of
views demands.

Secondly, I think we still go too far overboard in muddying the
distinction between why we\'re doing this and the issue of organ
allocation. Once we\'ve said in the beginning that we\'re not doing this
for organ allocation but we\'re doing it to define a standard by which
futile treatment of irreversible damage is no longer possible, that
seems to me to be a much more sufficient and clean medical distinction
as an end point, rather than to keep bringing up the consequences of
this for organ allocation. That\'s being dealt with in another report
that we\'re doing.

And then there was one rather egregious error in terms of where the
antidiuretic hormone is released that needs to be taken care of.

But those are my three general comments. I had a lot of little
nitpicking comments. But those are my two general conclusions and the
error.

CHAIRMAN PELLEGRINO: Thank you very much. Thank you very much, Dr.
Bloom. That\'s precisely what we would like to hear, the careful
analysis of this particular presentation.

Let me say that we\'ll be asking all of you at the end of this
discussion over the next several weeks to provide us with further
comments in writing and, as has been the custom of the Council from the
beginning, Council members may present their own opinion of the matter,
and I appreciate very much the careful thought you\'ve given to it, and
we\'ll certainly correct that matter of the antidiuretic hormone.
Several of us missed that.

Dr. Alfonso Gómez-Lobo?

PROF. GÓMEZ-LOBO: Thank you. I wanted to take up one of the points
raised by Floyd just from my own perspective.

I think the reason to go back to Shewmon\'s position is that, if Shewmon
is correct, it\'s really a major challenge to the idea that whole brain
dysfunction is an adequate criterion for death. I mean, if it\'s true
from his meta-study that there are all of these functions that continue
to be discharged by the body --- I\'m looking at Page 36, for instance
--- such that he can talk about chronic whole brain death, then, of
course, that is where the main challenge is at present it seems to me.

I mean, if, indeed, the rationale for the Harvard Commission is not
correct --- in other words, if it is simply not true that the brain
discharges the function of providing for the integration of the body
such that there is a number of functions, integrated functions, that
continue after that happens --- it is a major problem.

I must confess, being an outsider of these matters, that I\'m perplexed.
I would like to see the arguments really set out on both sides. I would
even go as far as wanting to have Dr. Shewmon testify. I mean, I really
want to see what\'s the depth of his thinking on these matters.

Now if you think that the evidence is inadequate, that Shewmon\'s
position can be dismissed because, say, there\'s a misdiagnosis of the
case of whole brain death, that\'s another possibility. But I would have
to see the evidence for that. Thank you.

CHAIRMAN PELLEGRINO: Thank you.

DR. BLOOM: Well, I\'m sure others will contribute to this discussion.
But my comment in the margin of Page 36 is that none of these equal a
living person. And I have no idea who Shewmon is and from what basis of
experience and knowledge he draws his opinions, but I find them
fallacious.

DR. FOSTER: Could I just say also that I don\'t know what the evidence
is for, I mean, real evidence on any of these things like that the
immune system is still working and fighting off infections. That seems
to be a bizarre claim to me. I mean, what is the evidence for that? I
mean, there\'s not evidence at all.

And amongst the other things, by the way, Renin is misspelled in that
chapter. It\'s R-E-N-I-N for whoever is doing that, so.

Anyway, so I agree with Floyd about that. There are these enormous
claims. And meta-analyses do not really answer anything, I don\'t think.
But to make these, I said the same thing. All these claims that a
brain-dead person can do, like an intact immune system, I don\'t know
where that comes from.

PROF. GEORGE: Just so I can be clear, Floyd, are you and Dan disagreeing
on the question of whether these are good indicators of death or life,
or are you disagreeing because Dan doesn\'t think that what we would
ordinarily call a brain-dead person is actually capable of manifesting
these factors set out on Page 36?

DR. BLOOM: Well, my take is that, even if they were true, they wouldn\'t
be life. Now, Dan is questioning whether they\'re even true. But even if
they were true ---

PROF. GEORGE: Dan, from your point of view, if they were true, would
that manifest the existence of organismic wholeness or integration so
that we would have a life?

DR. FOSTER: No. I would not. I agree with Floyd about that. I don\'t,
and I want to make it clear. I have not made a systematic study of this.
You know, if you\'re going to ask a question, a scientific question,
about the immune system or something, I have not studied all of the
data. I\'ve just looked at what he has said.

So, yeah, I don\'t think a part of something is life. Look, if I take a
liver out of an animal, which I\'ve done about a hundred thousand times,
you know, and profuse it, it will do everything single thing that a
liver in vivo does and in which you discover all sorts of things. It\'s
working. We\'ve done it for very long periods of time.

It would be a little unusual to me to say that the fact that this liver
is working is some sign that there\'s life in the animal from which it
came. That\'s a silly statement because the animal has obviously been
euthanized. But the point is that the fact that an organ can be kept
alive or stays alive for a period does not mean that there is any
continued possibility of life.

If this was an argument that, if you stopped the respirator, somebody
would start breathing again and would do that if that was possible, then
you might have an argument I think.

The fact that something works for a while after that, I mean, these
things work all the time. We take out hearts, and, you know, we fly them
across the country and so forth, and it will still work, I mean, to do
that.

So, yeah, my point is two, Robbie. I mean, this is not a big thing to
me, this whole issue that we\'re talking about here. I mean, dead is
dead. I mean, I don\'t know how many times I\'ve declared it, just what
the initial comments were.

But my points are two. I\'m suspicious of the evidence that\'s had such
an emphasis in this paper because I don\'t know where that came from.
And as a physician scientist, it looks very doubtful to me, the claims
that he has said here. The second thing is, to me it doesn\'t alter the
argument that the person is still alive just because, let\'s say, the
nails grow or something like that.

PROF. GEORGE: Dan, if you removed a heart or a liver from an animal,
would it be possible that that part, that organ, could fight infections
or maintain body temperature? These are what the claims ---

DR. FOSTER: That\'s not really something that a liver or a heart does
anyway, you know, I mean, that does that.

But I\'m also very suspicious. I mean, I think he says that the body
temperature drops. You know, it\'s not maintained at a normal fashion.
With blankets, yeah, I mean.

CHAIRMAN PELLEGRINO: Dr. Kass?

PROF. KASS: Thank you. Let me make a couple of general comments. I also
agree with Floyd that this is a much better draft, and I\'ve provided
both the micrographic comments and also a slightly longer comment which
I think would help beef up the argument defending the use of the
neurological standard. I sent it too late by e-mail, and there are
copies here for you to look at as you wish.

And I also think perhaps we\'ve made too much of Shewmon. But the fact
that the question has arisen and that there are still a lot of people
who talk as if there\'s brain death and then there\'s death indeed,
it\'s probably useful to try to clarify this in the way in which this
report is done. And I think this is a very valuable contribution, and
I\'m very happy to see its evolution to its current form.

Second, the Harvard criteria report, notwithstanding the mixed motives,
I think, did a very fine job in laying out the criteria for determining
whether you still have a living human being in the presence of a
ventilator which might, in fact, mask the truth of the matter.

They were very careful not to elaborate any concept of death or give
even some kind of theoretical justification. It\'s a set of operative
tests, and those tests more or less continue as we have them.

The trouble started when people tried to articulate the justification
for this in terms of some understanding of why the complete dysfunction
of the entire brain constitutes the equivalence of the death of the
organism as a whole. And in that paper by Burnett, et al. the concept of
integration took very great providence. And it seems to me it is that
which Shewmon is after when he raises at least some of these objections.

And, I mean, I would share, I think, Dan\'s desire for more evidence on
many of these points. But I would be inclined to think that certain
things, at least in some cases, have been noted.

But those kinds of somatic integration don\'t, it seems to me, add up to
the existence of the living organism doing the work of the organism as a
whole.

So here I think this is Floyd\'s point, and you also agreed with it. I
would grant Shewmon all of these things and say \"very interesting.\"
But even in the presence of those things, one could still say that the
organism as a whole is no longer with us.

And here, just a small comment to Diana\'s very elegant opening. I think
the emphasis on commerce with the environment does make it look as if
foreign relations are of the essence, and this comes out, I think, in my
suggestions for redrafting it.

I think what Alan wrote and is really very nicely hit on is, let\'s not
talk about integration. Let\'s talk about the work, the essential work,
of the organism. The essential work is its capacity to maintain itself,
and that activity of self-maintenance requires, on the one hand, an
inner drive to do so, the ability to act on the environment at least
minimally to provide the that without which there could be no organic
life, and some kind of responsiveness to the world, at least minimal
responsiveness.

And it turns out that he\'s given a kind of intellectual justification
for using these criteria that the Brits use, which is to say, no
awareness and no breathing. If you can\'t do that, you can\'t do.
That\'s the ground. That\'s not the highest thing that an organism does.
That\'s not the reason that all of us want to stay alive.

But absent that foundation, there isn\'t anything. So I think this
report stands a chance of rescuing the criteria giving it a sounder, not
foolproof, but a sounder philosophical defense in which Shewmon\'s
objections can be acknowledged and bypassed. And I think this is a real
contribution and would give lots of people much greater comfort that the
doctors who proceed primarily without these philosophical reflections
are doing the right thing.

CHAIRMAN PELLEGRINO: Thank you. I have Dr. Meilaender and then Dr.
Dresser.

PROF. MEILAENDER: I want to make one comment about Floyd\'s second point
and then a comment about the most important issue that\'s arisen.

Your point, your second point, Floyd, was something like there was too
much emphasis at the start on the organ-transplantation allocation
issue, and the alternative that you suggested was, sort of, when
treatment is futile.

To me, that doesn\'t quite get it right because the issue is, the real
question is, it\'s not just organ allocation. I agree with you on that
point. The question is when you have a corpse. And if you have a corpse,
it\'s not that certain treatments are futile. It\'s that the very
concept of treatment ceases to be relevant any longer. And so I just
wanted to sort of clarify that in a way.

Now to this other issue. I mean, I can\'t evaluate Dan\'s and Floyd\'s
objections to Shewmon\'s thing. I\'ve taken it seriously just because
people in the bioethics world seem to have taken it seriously. I have no
better reason than that, I suppose, for doing so.

But it has been taken as a serious challenge to the use of the concept
of integration as sort of the mark that we\'re looking for to
distinguish between a living and dead being.

I mean, I think it\'s true. Dan\'s illustration of the liver is nice.
The alternative that\'s being developed here is that it\'s not just that
the body continues to be able to integrate certain functions of one sort
or another, but that the living being is still present.

And the attempt to provide a different account of that here, I think, is
a really potentially excellent contribution. At least it seems to me
that. I mean, it\'s not clear that the integration concept in and of
itself works.

We\'ve got something else going here, what Leon just summarized a moment
ago. And I find it both interesting and potentially significant as an
alternative explanation of why total brain dysfunction seems to us to be
so significant.

I actually think also --- but this sort of goes beyond what we need for
this report --- that it\'s a philosophically fascinating alternative
that\'s being offered, what Leon just characterized as the organism\'s
capacity to maintain itself shown in both an inner drive and an openness
to the world.

I mean, there\'s something quite interesting in the fact that
maintaining oneself requires an openness to the world. I mean, I think
actually the implications of that are much larger than just a question
about transplantation.

So I think we have a potentially really significant contribution here
saying something that hasn\'t --- it\'s not that nobody has said it
before. But it hasn\'t played the important role in these discussions
that it could, and I think it\'s a very useful thing to put forward.

CHAIRMAN PELLEGRINO: Dr. Dresser and Dr. Hurlbut.

PROF. DRESSER: I, too, think that the report is much improved, much more
accessible and clear to educated lay people, and I really congratulate
you on that.

A couple of specific things. On this list by Shewmon on 36, I know from
the movies, I think, that when people die in the ordinary way their hair
grows and their nails grow, and I was wondering if there are other
things that apply to people declared dead by the cardiac standard that
could be cited as examples of things that continue to go on but we still
consider them dead, to respond in part to him.

The second thing I wondered about was on Page 10 where there is a
discussion of acknowledging whole brain death, we can\'t really know
that those people are dead. But organ transplantation is a benefit to
society that we want to maintain even if we cannot know that the donors
are dead.

The main proponents of the view that we should abolish the dead-donor
role in my reading are the ones who want to say more like, \"Well, maybe
the people with whole brain death are dead. But there are other people
who don\'t meet that standard. There are severely brain-injured who are
close enough that we should be able to take their organs.\"

So the way this was presented struck me as a different framing of that
argument. Later on, the other one is presented. So I just wondered if
whether that was something that would be confusing or kind of throw
people off. So that would be something to think about.

And then the third thing was in the donation by cardiac death toward the
end. I thought that part was a little bit too truncated. For example, on
47, it\'s discussing this irreversibility question and mentions at the
end that traditionally physicians don\'t rush to declare death, and
it\'s kind of a notion of recognizing the dignity and the mystery and
the dying process not to run to somebody\'s bedside and say, \"Okay.
They\'re dead.\" And I thought that was good material.

But then I wondered, \"Okay, well, what is the point?\" The next
paragraph just kind of says, well, this is something society needs to
think about. And I just wondered if we could do a better job of drawing
some conclusions or sort of just finishing off that part in a more
eloquent way.

But other than that, I thought it was very, very well done.

CHAIRMAN PELLEGRINO: Thank you, Dr. Dresser. Dr. Hurlbut?

DR. HURLBUT: So I want to get back to what Floyd started and try and
engage Floyd and Leon in this dialogue because I think there might be
something really substantive there, and Dan, too, here.

First of all, I know Alan Shewmon personally. I\'ve talked with him
about these matters. He\'s a neurologist on the faculty at UCLA, at
least he was when I talked with him. I haven\'t talked with him in three
or four years, maybe a little longer.

And I think what he\'s doing here is something that is, indeed,
thoughtful and challenging to us and important for us to consider. He\'s
a very thoughtful person and a very earnest person.

And I think we should take seriously what he\'s saying, that if we\'re
going to fairly superficially define life and death by some notion of
somatic integration, then we have to take seriously that, as he says,
the functions of the body that one would say define integration are, in
fact, whole body properties, that they are emergent properties of the
whole, and that they reflect the well-working whole and they reflect
what the organism as a single unit does.

So then the question becomes, well, if there are systems --- and Dan may
be right. He may be exaggerating these. But if you look at what he\'s
saying, he says there are these troubling evidences on the edges of
this. This meta-analysis may or may not be right, but there are enough
troubling issues here.

He points out that certain body functions do seem to involve more than
what you might call a part. They involve numerous parts of the body
acting together. And so then the question becomes, well, now are these
really what you would call somatic integration in the fullest sense or
are they just subsystems?

And there\'s where I think we might have traction on what Floyd is
talking about, that, in fact, just as the body has parts, it also has
distributed subsystem functions that don\'t rise to the level of what we
could reasonably call the action of the organism as an integrated unity.
And that\'s where I think we might get some traction, and I\'d like to
ask you to further explicate that.

But just a couple of more comments before you do that. I think what Alan
is worrying about is, we all know now that DNA essentialism isn\'t a
very good picture for how genetics works. It puts the emphasis too much
on the DNA, which, in fact, is just a component of a larger system.

I think what he\'s getting at is, we have to be careful of not
establishing what we might call neural essentialism to say that the
person is the neurons operating in a certain way.

But what I would like to suggest is that, while there may be subsystems
of the body, these subsystems are, in fact, joined and become integrated
when the brain is operating. And when it isn\'t operating, they are
fragmentary subsystems, and you can go on with that.

But I\'d also like to put a question to Leon and that is, what do we
really mean by integrated unity for an organism and might not this
integrated unity differ in the kinds of organisms we\'re talking about?
And I\'m thinking specifically here about parasites.

To me a crucial term in all this might be the self-subsistence that
characterizes an organism, and, yet, there are differing degrees of
passive and active natural existence for organisms. And here the
ventilator almost feels like the relationship between a host and a
parasite where something is supplied that other organisms supply for
themselves.

So the question then becomes, do we need to define human wholeness,
human integration, by somewhat different criteria than we might for
other organisms? And that brings us back to the special types of active
agency that human beings have.

And so I would specifically like to ask you to articulate, Floyd, what
you would find inadequate about Alan Shewmon\'s ideas and what you would
define as the integrated unity of the organism, and to ask Leon,
specifically, what he might say about the species-typical dimensions of
commerce and whether there might be something specific to human beings
that we might focus on?

And, finally, I do want to get back to this one or at least mention it,
if it\'s appropriate now, and that is, beginning on Page 6 in our report
we use this word \"health\" I think a little casually. It says, \"This
means that surgically-procured organs will be in relatively good
health,\" and, of course, \"health\" means wholeness, and that\'s really
what we\'re trying to get at in our definition.

And I just want to raise the question for the Council as to whether we
should reserve this word \"health\" for what we\'re really talking
about; namely, the well-working whole. And I know it\'s used
colloquially. \"Their healthy organs have been procured from the dead
donor.\" But I wonder if that is something we ought to not fall into,
but speak of health in its proper relationship to the living whole.

So what do you think, Floyd?

CHAIRMAN PELLEGRINO: Dr. Bloom and Dr. Kass?

DR. BLOOM: Just to be very succinct in my responses, the reason I raised
the issue of who is Shewmon is that, if I had known he was
medically-trained and a neurologist, I would have given more than just
passing attention to what his comments were. If his background was in
philosophy or law or something else, these would be things that he had
read but not necessarily been able to interpret. So giving even a
footnote of background on who he is at least establishes for me that at
face value I have to listen to what he has to say even though I think
he\'s wrong in what he has to say.

And, secondly, let\'s take some examples at the periphery where all of
these things are going on. The person is even breathing, but they are
not interacting in a constructive or a responsive way with their
environment. Are those people alive or dead?

The Schiavo case, the Karen Quinlan case, where death was only allowed
by virtue of stopping the feeding tube, because all these things on Page
36 were going on but that person was not in their environment, I would
have said that maintaining that, as the physicians who made the decision
finally did, that this was futile treatment, that there was never going
to be any recovery and the case should have been closed.

You can get by with no kidneys, you can get by with no liver, you can
get by for some time with no heart, and the brain is still functioning.
Those people have an opportunity to be repaired. But when the brain
isn\'t there, it doesn\'t matter what the rest of the body is doing.
That person is never going to be a person.

CHAIRMAN PELLEGRINO: Dr. Kass, do you wish to comment to Dr. Hurlbut\'s
question?

PROF. KASS: I\'m first moved, Floyd, if you don\'t mind, to underscore
something Gil said in response to the last time the notion of futility
was raised by you.

It\'s very important, at least for the purposes of this document --- and
maybe not everybody agrees --- that we distinguish the question of when
continued treatment is futile because no good will come from it and when
what looks to be treatment is mistreatment because you have a corpse
whose corpse-like nature is hidden by the fact that the chest is
heaving.

And no one, I think, would say that Terri Schiavo was dead. She might
have been dead as a \"person,\" whatever that means. But no one would
have buried her. One might have been warranted or not in taking the
feeding tube out, but that was a decision to discontinue life-sustaining
treatment, not a question about pronouncing her dead.

And I think we should remain very clear about the confines of this
report. I don\'t think you disagree, but I think the wrong impression
might have been conveyed.

Bill\'s question, I\'m not prepared to do very much with on one leg, but
I don\'t think you could talk about the many complicated ways in which
the human being does all of the human work.

The question at the margins at the edges of life is there is still the
human organism present, not the powers to philosophize or to make moral
judgments present. Those might enter into the question of how vigorously
to treat or not. But the question here is, is the patient still here or
not? You know, is it still a member of the human community or is it time
to call the undertaker?

And for there, I think you\'re talking about kinds of minimal and
foundational activities of the work of staying alive without which none
of the higher things are possible and in the absence of which I don\'t
think you would say that you have an organism.

And here I think the difference between the living human being and the
living chimpanzee, the living or dead human being or the living or dead
chimpanzee or the living or dead dog are probably very comparable.
Parasites and amoebae and bacteria are, you know, far away.

But I think we\'re talking about a mammalian organism, the life and
death of which looks fairly similar. I mean, I could be disputed. I
think Floyd and Dan might have a different take on this. But I don\'t
think you need a kind of fancy account of the specifically human
character of the organism to look for things that are distinctively
human in deciding whether we\'ve crossed the line from living or dead. I
don\'t know if others would agree.

CHAIRMAN PELLEGRINO: Dr. Lawler and Dr. George?

PROF. LAWLER: I\'m approaching this from the discredited foundation of
philosophy and law ---

*(Laughter.)*

--- and I think it\'s a real problem here from a common sense point of
view.

We do want to know when a corpse is a corpse. We do want to know when
dead is dead because you can have truth in quotes. You can have morality
in quotes. But you don\'t want to have dead in quotes, like post-modern
dead.

Although in the short term, there may be some question. In the long run,
we know death when we see it. It\'s just this gray, maybe gray, area
among the newly dead that causes us distress.

And I think it was well put. It\'s not, you know, when is treatment
futile, which was the Terri Schiavo issue, but when is treatment utterly
ridiculous because you don\'t treat corpses. And most of us wouldn\'t
want to cross the line when it comes organs, of taking organs from
beings who aren\'t really dead, not sort of dead or will be dead soon or
something like, but actually be dead.

So I think Shewmon has caused in the world of bioethics real doubt; that
is, integrated, somatic functioning which was the basis of the medical
consensus turns out to be a question because there does appear you can
give an argument that the being continues to have that kind of
integrated, somatic functioning even if the brain is not working.

So why would anyone care about this? Why would an average guy like me
care about this? Because some people want to give the most expansive
possible definition of life. When in doubt, go with life.

So a lot of people want to protect embryos, not because there\'s a
slam-dunk ontological case that the embryo is a human person, but
because the embryo might be a human person. And when in doubt, choose
life. And in the same way, when in doubt, choose life, and so the guy on
the ventilator whose brain is not functioning might be alive; therefore,
choose life.

So I do think people of good will are shaken by Shewmon. People of good
will who read stuff like that are shaken by Shewmon. So we need a new
argument, and the big question before us is, is the argument of needful
openness really a slam-dunk argument? Question number one is, that\'s a
slam-dunk argument. Or the other point of view of Dan and Floyd is, we
don\'t need a new argument because we weren\'t shaken. But some people
have been shaken.

But that means a need for openness becomes a question because it\'s so
darned philosophic and so darned interesting and so darned complicated,
as Diana pointed out, and perhaps so darned questionable in its own way.

So does needful openness solve this problem that\'s come before us, or
does needful openness show us that we have a pretty good argument here?
But because it\'s philosophical in a certain way, does it really provide
what we really need to extinguish the doubt or were we wrong to think
there was doubt that needed to be extinguished?

But in Diana\'s remarks, she said at the very end --- I think she was
saying --- I have some doubt; nonetheless, I\'m going to go with the
established medical consensus anyway.

CHAIRMAN PELLEGRINO: I have Dr. George and Dr. Gómez-Lobo.

PROF. GEORGE: Thank you. I agree with Floyd that we need a footnote
telling us who Shewmon is. As it happens, I know him and know about him.
He is a person of distinction. He is a clinical professor of pediatric
neurology at UCLA, and he\'s the chief of neurology at the Olive View
UCLA Medical Center.

But if we\'re going to engage the work of a person, any person, in the
extensive way we do in this draft, then we need to tell readers as well
as ourselves who the person is.

Shewmon has become a very important figure, I think deservedly so, in
bioethical discussions. And his work is engaged and treated with respect
interestingly across the spectrum of views in bioethics. But I think it
is important that we understand that, you know, his principle
contributions are in his area of expertise, and this has to do with
factual scientific claims of the sort that Dan has doubts about and
wants to know more about and wants to know the evidence about.

He\'s also intervened or entered into the neuroethics debate and the
bioethics debate, and there, you know, he is certainly a welcome
participant and has interesting things to say, but they are not within
his specific area of professional expertise, and so I think a
distinction can be legitimately drawn there.

So what I would suggest is that we do look closely at the specific
scientific claims, factual claims, being made by Dr. Shewmon. And
perhaps it would help Dan if we instructed the staff to look at the
literature to see what criticisms have been advanced if, in fact, there
are criticisms, and I suspect there must be if this has struck you right
out of the blocks as having problems. We could have the staff look at
the criticism that\'s emerged in the literature of his scientific
claims.

Now I know there\'s plenty of criticism on the ethics. But, again, that
I think is secondary to the specific use being made of Shewmon here. So
I think that\'s one specific suggestion that I hope we can make to the
staff because I think it would strengthen the report.

Because of his importance in bioethics and the importance of the
questions that he raises, I\'m in favor of retaining an extensive
engagement with Shewmon in the document. But I\'m proposing to enrich it
by looking at what critics have said.

CHAIRMAN PELLEGRINO: Dr. Gómez-Lobo. Thank you.

PROF. GÓMEZ-LOBO: I\'m glad that we\'re having this discussion around
Shewmon. But now I would like to support something that I understood
Leon to have said a few minutes ago, and I emphasize it because I think
it should be something like a common ground in these discussions;
namely, that the notion of death has to be a notion that transcends
classes of living being.

I think we have one basic understanding of death, and it is the
permanent cessation of life. Stones don\'t die, but trees and birds die.
And this may seem trivial, but I think it\'s not because much of the
literature on this subject is entitled, for instance, changes in the
definition of death. And that, I think, is a very serious philosophical
error.

If you change the definition of the term, you\'re talking about
something else. If you change the definition of a triangle into a plane
figure with four sides, then you\'re no longer talking about triangles.

I think for the sake of clarity it\'s important to realize that we and
the generations before us are talking about the same phenomenon. It\'s
the cessation of life of organisms of any kind.

The debate is, as the report and its very good draft that reads, a
debate about standards, standards or criteria for establishing this. But
there has been no change in the definition of death. In fact, if it
were, we would be talking about something completely different.

So I would suggest, and the report I think does this, to keep that as
the ground floor. We are discussing standards. We are not discussing new
definitions of death.

Thank you.

CHAIRMAN PELLEGRINO: I have Dr. Schaub, Lawler, Meilaender, and Dr.
Rowley. Thank you.

PROF. SCHAUB: Yes. Just a very quick question maybe to Leon about the
drive for self-preservation. Why wouldn\'t we say that things like the
sexual maturation of a BD child or the gestation of a fetus, how is that
not indicative of the presence of a drive to self-preservation and, not
only self-preservation, but the next generation?

CHAIRMAN PELLEGRINO: Can I interrupt the flow to give Leon a chance to
respond to Diana? Yes, please.

PROF. KASS: No. This might not be right, but my first impulse would be
to say that if you could profuse and ventilate a corpse so that it
becomes simply an, as it were, incubator for a life that happens to
reside there rather than see it as the continued work of what would have
been the mother, I imagine it would be possible to sustain fetal life in
lots of unnatural places and this would be one of the first such.

PROF. SCHAUB: Could it a BD woman conceive?

PROF. KASS: Could a B?

PROF. SCHAUB: A brain-dead woman conceive? Not only gestate a fetus, but
conceive?

PROF. KASS: I\'m going to declare ignorance, Dan.

DR. FOSTER: Well, I think that would be miraculous. I mean, I don\'t
want to get into the integration of the C and S and so forth around
here. I mean, there is powerful new information, for example, that
neurons in the brain control the metabolism of glucose in the body. This
is a new nature paper that\'s just out.

The intricate hormonal changes that allow one to not only conceive but
then to bear a child are so complicated. Look at what we have to do to
try to get artificial children, you know, I mean, to do that.

So somebody who has tested brain dead? I mean, you know, Lazarus rises.
So maybe that would happen. But I would be very skeptical about that
because of the intense integration of multiple organs to allow a fetus
to be formed and, you know, and to grow to ---

PROF. SCHAUB: But we do know that gestation has taken place for periods
of weeks or months.

DR. FOSTER: Well, I think Leon\'s statement --- again, this is not
something I know a lot about or really am very interested in. But what
he said is presumably one of the things that we talked about in stem
cells, would it be possible for us with an artificial uterus to raise
parts and so forth along those things?

What Leon said is, \"Well, okay, if you put a fertilized egg in an
artificial uterus, you likely would see it grow up to some point.\" So I
don\'t think that\'s what you\'re asking. I think you\'re asking by
normal courses, could you get pregnant or along those things?

I don\'t know this, but I\'d be pretty doubtful, for example, that the
changes in vaginal lining and everything else are normal because you\'re
not generating. You know, you\'re going to have panhypopituitarism and
everything else, I would think. So I don\'t know the answer to your
question, but I\'d be very doubtful.

CHAIRMAN PELLEGRINO: Dr. Lawler?

PROF. LAWLER: Let me just underline that the whole premise of this
report is that Shewmon\'s challenge is important, and the great thing
about the challenge is it\'s spurred us to deeper reflection about the
distinction between life and death.

So let me just read the sentence right in the middle of the page on Page
41, the third paragraph. \"Thus, total brain dysfunction can\...
continue to serve as a criterion for declaring death, not because it
necessarily indicates complete loss of integrated somatic functioning,
but because it is a sign that this organism can no longer engage in the
sort of work that defines living things.\"

So the point of our report --- and I think it\'s a really important
report, very well done --- is that given this doubt, we need a new
argument. If the doubt is not worth considering as a genuine doubt, then
we don\'t need a new argument.

But I actually think, my own opinion would be, the argument is presented
brilliantly. I\'m like 98 percent persuaded by it. And from that point
of view, it\'s a really great contribution to our understanding of what
death is. But if Shewmon is bunk, then we don\'t need it.

CHAIRMAN PELLEGRINO: Dr. Meilaender and Dr. Rowley.

PROF. MEILAENDER: Well, this may not be necessary now that Peter made
his most recent comment which seems to me to cut, you know, in a little
different direction of his earlier one.

I was going to reply to his earlier one where he had said that this new
argument was so complicated. And obviously it is complicated in one way.
I\'m not sure it\'s anymore complicated than the argument it intends to
replace about bodily integration.

In another sense, it\'s very simple. It\'s an attempt to provide a very
basic kind of understanding or explanation for why we\'ve been drawn to
the sort of standard we have for distinguishing between living and dead
human beings.

So, yes, it has its complications, but I think in another sense it\'s
very simple. And I\'ll just repeat, to come all the way back to Diana\'s
opening remarks, that part of the attraction of it to me and part of
what strikes me as right about it is that what it recognizes is that you
can\'t actually entirely distinguish between domestic and foreign
policy, that the two are inevitably connected in a living organism.

CHAIRMAN PELLEGRINO: Thank you. Dr. Rowley?

DR. ROWLEY: I have three short questions or comments.

On Page 14 at the top under Item 3, the staff says, \"The concept of
death and the selection of the appropriate standard for determining it
are not strictly medical or technical matters. They are in large part
philosophical.\"

And I wonder. That struck me as strange because I have thought of death
and the standards; i.e., firstly, the loss of cognitive function as well
as the loss of respiration and cardiac are standards set by medicine not
by philosophy. But I raise that as a question. That struck me as
strange.

The second question that I have, I, as well as I think most members of
the Council, received an e-mail from Mike Gazzaniga, who was unable to
be here today, about a report from the Vatican. Now I haven\'t seen that
report, and at least Mike was very laudatory. So I think that, as we are
working through this report, it would be prudent for us to have access
to that because I gather from his comments that the council assembled by
the Vatican did agree in the concept of brain death.

And that leads me to the third comment which is, we\'ve chosen to use a
new term \"total brain dysfunction.\" And I wonder if that\'s really
going to be useful in this in the context of trying to help resolve some
of the issues that we\'ve been dealing with. Thank you.

CHAIRMAN PELLEGRINO: We have time for one or two more comments. Leon and
Dr. Lawler.

PROF. KASS: Mr. Chairman, this isn\'t so much a comment as it is a
question. In the draft we received, there is a blank page at the end
which says, \"Council Recommendations/The Position of the Council.\"

What kind of thing might appear there? I mean, are we going to be asked
either individually or collectively to weigh in on one or another of
these views? That\'s just, you know, a question.

CHAIRMAN PELLEGRINO: Questions? Comments? Peter?

PROF. LAWLER: I did with someone else\'s help a quick Google search on
the Vatican and on this issue, and I just came up with the news service
blurbs. So this is very unauthoritative and probably shouldn\'t be in
anyone\'s record.

But nonetheless it seems that I discovered that the scientists that
advised the Vatican are actually divided on this now. So Bishop Fabian
W. Bruskewitz of Lincoln, Nebraska whose paper from the 2005 meeting is
included in *Finis Vitae* asked how the Catholic Church can accept a
lack of brain function as a definition of death and yet still oppose the
willful destruction of human embryos which have not yet developed a
brain.

So I\'m not saying the bishop of Lincoln is necessarily the world\'s
greatest scientist, but he seems to be scientific enough to have
presented a paper. And it appears at the meetings at the Vatican there
was a disagreement over whether brain death is still an adequate
definition of death.

CHAIRMAN PELLEGRINO: Thank you. Gómez-Lobo?

PROF. GÓMEZ-LOBO: I was going to say something similar to that. I think
that Mike may be wrong in calling it a report because the Vatican
publishes lots of things with which they don\'t agree. For instance, if
you take the yearly reports of the Pro-Life Academy, there\'s lots there
that are just the papers that people have submitted.

So I think we should take a look at these documents, but they don\'t
reflect, say, something like official teaching of the Catholic Church in
any way.

CHAIRMAN PELLEGRINO: Thank you very much.

DR. FOSTER: I would just make one other point about Mike\'s thing. We
talk about Shewmon being

--- you know, he\'s the head of pediatric neurology at a private
hospital, I guess, that\'s associated with UCLA.

But Posner, who is quoted here, clearly is the senior neurologist, you
know. He involved hepatic encephalopathy. I mean, that would be a person
who is universally recognized at a different level of clinical
neurology, I think, in terms of this conscious. And if he was quoted
correctly, he would be very much in agreement with the sense that the
brain is absolutely critical to life, you know.

You can define life. If you listen to my lecture to biochemists at the
medical school next week, you will hear my definition of life, and it\'s
a molecular definition. Life is the capacity to generate high-energy
phosphate bonds. Death occurs when you can\'t generate ATP. Okay?
That\'s what death is because that\'s what keeps everything else going
at a molecular level.

So, you know, the arguments vary one way or the other about what you
define and how you want to define it.

CHAIRMAN PELLEGRINO: Thank you.

DR. BLOOM: Well, I just wanted to respond to Janet\'s third point about
total brain dysfunction not being the most mellifluous way to express
what it is we mean. And I had suggested to Alan that we might consider
using the term \"brain failure.\"

Heart failure, liver failure, kidney failure are all well in the
public\'s mind, and they\'re not necessarily specific as to the
mechanism by which that organ has failed. And what we\'re talking about
here is brain failure.

PROF. GEORGE: Could I ask Floyd a question about that, again, just to be
clear?

Floyd, when you talk about brain failure, are you talking about what
afflicts a person who is in a persistent vegetative state, or are you
talking about what we have heretofore referred to as a brain dead person
as opposed to a brain damaged person in a PVS state?

DR. BLOOM: I was talking about it in the sense that Peter\'s last quote
from Page 41 talks about it and the inability of that individual to
interact with the environment as the work of the individual.

PROF. GEORGE: So would a PVS patient have brain failure?

DR. BLOOM: It has a form of brain failure, yes.

PROF. GEORGE: So such a person would be dead?

DR. BLOOM: That\'s where we are.

PROF. GEORGE: But not according to the brain death definition that we
have been working with and that Shewmon and others have called into
question.

But I think it was Leon who said, I mean, no one was saying you can bury
Terri Schiavo. The debate is about whether you could take steps that
would result in her dying, the assumption being she was alive before
those steps are taken. Am I wrong about that?

DR. BLOOM: I should let Leon answer that question because it was he who
raised the actual complex dividing line.

PROF. KASS: No. I thought I was going to come to your aid, Floyd, and
say all you need is total brain failure. And you would say of Terri
Schiavo, not quite total.

PROF. GEORGE: So she wasn\'t dead?

PROF. KASS: That\'s what I think, I mean, by these criteria.

PROF. GEORGE: I\'m happy enough to go along with the use of the term
\"brain failure\" if it refers to what we generally refer to and have
been referring to as brain death. Then we can talk about whether we want
to retain that understanding of death.

But I would be very dubious about moving forward if we\'re identifying
brain failure with death and we would understand people who were in
persistent vegetative states as having brain failure.

CHAIRMAN PELLEGRINO: Dr. Carson?

DR. CARSON: I just want to bring it back to a practical level because,
you know, as a neurosurgeon, we deal with these things of brain death
and brain failure all the time.

And, you know, we in the medical profession know what a brain dead
person is, and there really isn\'t a whole lot of controversy about, you
know, ceasing to treat those individuals except if organ procurement is
on the table.

However, the ones who have significant brain dysfunction engender a lot
of discussion. People recognize that they are not dead. However, they
also recognize that they are not people who are not going to make any
kind of a recovery.

And in those situations, what is practically done after discussions with
the family are measures are taken to allow them to move on to the state
of brain death and then, you know, things are withdrawn at that point.

It\'s practical. It\'s done every day. And, you know, I just hope that
we can reflect some of the practicalities of what are done in normal
life in medicine.

CHAIRMAN PELLEGRINO: Thank you. Let me point out first in answer to
Leon\'s question earlier, yes, we would like to have your comments on
any recommendations we might make. I think we would like very much as we
indicate on the very last page of the material you have of the report
itself to know what you think about that on an individual basis to
repeat once again the invitation to each and every one of you to express
your personal view on this.

I take this to be, just as all of you do, an extremely important
question to be addressed. I\'m very much concerned, Robbie, about the
question you asked toward the end about the permanent vegetative state.
We had a presentation in which it was suggested to us that those
patients were eligible for removal of organs, and I personally would
certainly strenuously oppose that. But that\'s beside the point.

But on your question, Leon, we want to have further recommendations and
further emendations if possible. This is important enough so that when
we make the contribution it\'s clear that the opinions of the members of
this Council are expressed, and it\'s not the kind of thing where we may
be able to come to complete resolution of all the issues and make a
recommendation that everybody would agree to unanimously.

But our purpose is to lay out those issues for the public and where are
we on this important question, which leads me to the second point that
this report, of course, is related to the report which will be given to
you for the next meeting for a detailed discussion on organ donation
which you\'ve heard about and we\'re now at the point again where it has
been edited and looked at again and again and will be back to you for
further comment. So these two have a relationship one to the other.

And, Robbie, to just point out quickly, your question about the critics
of Shewmon, I think in Dr. Rubinstein\'s summarization of the paper he
did address the critics of Shewmon. I know that Dr. Bloom feels perhaps
we\'ve given too much attention to Shewmon, but Shewmon has raised the
question over and over again and I think it needs to be dealt with.

Insofar as the Vatican position goes, I think Gómez-Lobo has reported on
that. I\'m a member of that council as well. I won\'t take your time to
go into the details of the conversation.

But my general feeling is that the members of the Council do, indeed,
feel this is sufficiently important for us to give our very, very close
attention to it.

Dr. Dresser?

PROF. DRESSER: In terms of recommendations, I think we could look at
Pages 9 and 10 for a barebones statement of the sort of objectives of
the report and then see whether that needs supplementation or there\'s
some concurrences and dissents and so forth. But that seems to me to
present a draft of recommendations.

CHAIRMAN PELLEGRINO: Thank you very much.

If there are no further comments, we\'ll break until perhaps, oh, 10:30
or 10:35 at the latest to reassemble. Thank you very much.

(*Whereupon, the proceedings in the foregoing matter went off the record
at 10:21 a.m. and went back on the record at 10:54 a.m.)*

CHAIRMAN PELLEGRINO: Can I ask the Council members to be seated please?
Thank you very much. We\'ll now resume our agenda.

The next topic for the rest of the day will be on the \"Crisis\" in the
Ethics and Profession of Medicine. And we begin with a very
distinguished commentator and author in this area, Dr. David Rothman.

I have explained to Dr. Rothman, who understands clearly, of course, our
custom which is not to provide long introductions, and he said he was
relieved, and I\'m glad. And so I will ask him forthwith to address us
and then the discussion will be opened when Dr. Rothman finishes.

PROF. ROTHMAN: Thank you. I can tease with Dr. Pellegrino. If you can
accumulate enough titles, you don\'t have to give your talk ---

*(Laughter.)*

--- particularly, you know, when you get these 20-minute versions of it.
I have longer today, and I very much enjoy the chance, A, to appear
before you and speak to you. I know several of the members of this
commission for some years. And, secondly, it\'s a good subject, and I\'m
hopeful that the pleasure that I got in sitting down and doing this for
you will be matched by your finding what I\'m about to say interesting.

Dr. Pellegrino and I are both members of that generation that came of
age well before PowerPoint. Since I was in arts and sciences before
going up to the medical school, I didn\'t even know from slides. We just
simply talked from notes or text. Yet, I have converted and Dr.
Pellegrino is suggesting to me maybe in confidentiality rules --- I\'m
not sure --- that he\'s beginning a little bit to convert to PowerPoint
as well. It\'s a very useful tool. So I haven\'t used as many as I might
otherwise have done out of respect for Dr. Pellegrino\'s bias. On the
other hand, it was hard not to at least be able to say something using
the technology.

I\'d like to open my analysis of the state of the medical profession,
the putative crisis it faces, and the locus of responsibility for making
change by recounting to this august group how another group responded to
the very same issues.

The group whose experience I\'d like to share with you is the Board of
Trustees of the Institute on Medicine as a Profession, IMAP, a 501(c)(3)
public charity of which I am the president.

IMAP itself was created through a generous gift from a noted
philanthropist, George Soros, a man who made his fortune in the
marketplace obviously, but a man who was totally convinced that
marketplace values should not dominate all sectors of the society. In
particular, the professions, medicine and law, as the exemplars, have
responsibilities that ought not to be driven by the market. This was
very, very much his position, a position that I share, and I suspect
many, if not all, in this room will share.

Doing justice from the legal side and promoting health in our territory
are obligations that go well beyond the bottom line. It was that kind of
thinking that led him to endow the Institute. The Institute itself
carries out its work through a center at Columbia College of Physicians
and Surgeons.

IMAP has a board of directors, trustees, if you will, and the first
meetings post the gift were devoted to defining its mission, the
Institute on Medicine as a Profession. As it would be expected, the
group wanted to spend a certain amount of time defining professionalism,
how it might promote it. But what might not be expected in these early
deliberations was a dialogue that we got into and actually stayed into
for a surprisingly long period of time. And it\'s that dialogue that I
want to recount to you.

The first impulse of the group was to set out the challenge, medicine as
a profession, and set it out in terms of a revival of professionalism.
We have to look back, recapture, restore, you know, if you will, all the
R-E words. Recent developments have eroded professionalism, the opening
hypothesis was, so our efforts should be revitalization, recovery. You
can fill in more and more synonyms.

But before we even could go very far down that path, we all recognized a
fundamental inadequacy of framing a program in terms of restoring ---
and I don\'t mean it quite pejoratively, but perhaps there\'s a little
inkling of it --- restoring the good old days.

So as the slide shows, we called it and we began to talk about it in
terms of the so-called good old days. Did we really want to revive,
restore, rediscover a profession that was all male, almost all white,
and almost all upper- middle class?

I keep wondering. You know, those photographs, you\'ve lived with them.
We have them at P and S, too. You know, the class of house staff from
1910 and 1912. You know those photographs: Lily white, lily male. I
mean, occasionally maybe a woman, maybe a person of color. But those are
stark white photographs. And we do know the socio-economic origins, the
upper-middle class, as well. So before one got too rhapsodic about going
back to the good old days, certainly we didn\'t mean to do that.

And then we would go into financial issues, which we\'ll be talking
about today. Conflict of interest was certainly present; fee-splitting,
an absolutely common habit. The surgeon had to reward the referring
physician. He did it in a T in a variety of ways, sometimes the charade
of that surgeon bringing in the primary care provider to the operating
room. One way or another, they figured out how they could gift, if you
will, the referring source. The practice hasn\'t altogether disappeared.

I love California wines, saw an advertisement in *The New Yorker* for a
kind of California wine-of-the-month club, was curious about it. On home
stationery, home stationery, I wrote and asked for the brochure. It came
back with a first-cover insert kind of thing which said, \"The perfect
way to thank the referring physician.\"

*(Laughter.)*

Somebody at that wine company knew how to market its product.
Fee-splitting isn\'t over. But, I mean, again, my caution is, we\'re not
going to get so rhapsodic about the good old days.

Direct dispensing. A not uncommon practice.

Fee-for-service. In a group like this, I don\'t have to expound on the
potentials of conflict of interest there. But certainly, you know,
returning the patient for a visit, it happened, part of the roster.

Drug company largesse, which we\'ll spend some time on this morning as
well. It\'s not a post-1990 phenomena. It goes way back and was, if
anything, perhaps --- well, I shouldn\'t say that. But it\'s
effectiveness may have increased. But it\'s certainly a phenomena as
part of the good old days.

And even public complaints about doctors\' income, which you see a lot
of in the press, nothing really new about that. The 1950s saw a spate of
journalist accounts of doctors including one that I always tell my
medical students that involved a child in a Midwestern town who fell
down an abandoned well.

He opens his book with this. The town spent about a day and a half.
Everybody --- you know, the fire department, the citizens --- digging,
you know, doing all the rescue operations. They rescued the child. They
give the child to the physician for care. The physician delivers the
care, and then the physician has the audacity to bill the family.

Well, this became newsworthy. How could you have billed? It made its way
to the AMA. As I followed the story, I wasn\'t sure what the AMA would
do. The public uproar was so great that the AMA said the doctor was
wrong. I tell this story, not for the rights or wrongs of the charge,
but that public complaints about physicians\' income has a long history.

Damned if you drive the Cadillac, damned if you don\'t. Patients want
their physicians to be \"big men.\" On the other hand, you know, I mean,
the only reason that I\'m playing this out for you is I don\'t want you
to think that the current kind of critiques have anything unusual about
them.

And the last two bullets are, of course, perfectly obvious to you. The
strong bias against group practice and the extraordinary bias against
government intervention, the case in point, of course, being Medicare.
So before you get too rhapsodic about restore and rediscovery, we really
don\'t want to go back to those good old days.

Then, you know, the dust would settle. Everybody\'s outrage, you know,
would calm down. And then we would say to each other, \"Okay. So our
task is to invent professionalism. If we can\'t restore it, we should
invent it.\"

But that was, again, a kind of frame that could not exist for very long.
Everybody in this room and everybody in that room knows it well. The
Hippocratic oath dates back and, you know, if you want to bring a laugh
to a medical audience, all you have to say is, there is no Hippocratic
oath for lawyers. It\'s the medical students at commencements who
recite, not the business school students. You know the rest of that
litany. And it\'s a powerful document, obviously amended by almost all
of the medical schools that use it.

But the key values --- confidentiality, do no harm, respect for the body
of the patient even if the body of the patient --- you\'ll remember that
line --- is the body of a slave. I mean, that\'s startling in its way.
So, I mean, invent when you have that kind of tradition?

And medicine as we do know and we recognize had a long tradition of
serving the under-privileged. In pre-Medicare/Medicaid days, there was a
Robin Hood quality about medical practice. Well-to-do patients paid
more. Poorer patients paid less. And many physicians to this day serve
patients\' well-being impervious to the clock, the day of the week, the
nature of the holiday. So invent seemed, if you will, totally
presumptuous.

We went round and round this cycle of revive/ invent several times, and
we soon recognized that the internal debate we were having matched up
quite well with the academic debate that had gone on within the history
and sociology of medicine over now almost the past 90 years.

In the 1930s, the major frame, analytic context for understanding
medical professionalism, was the work of Talcott Parsons, a famous
sociologist. I suspect some of you have read him as well. Parsons
treated medicine as the quintessential profession. This profession, he
argued, had a collective orientation, and he very, very clearly
contrasted it to business, which was self-interested.

For Parsons, the financial self-interest that business characterized as
normative was outlawed in ethics and the practice of medicine. He was
altogether confident in declaring that patients should put themselves in
doctor\'s hands, do as they were told, commit themselves to recovering.
No patient activism there. You listened to your doctor. You did as your
doctor told you.

Parsons did all his field work at Mass General. A very sophisticated
sociologist, he had no trouble thinking that Massachusetts General, MGH,
represented the world of medicine. Startling as we read him but very,
very much there, professionalism in his context and his influence, I
think you appreciate. Professionalism, doctors serving patients\' best
interest, was the hallmark of the field.

But in the 1950s and 1960s, a very different line of interpretation
comes to dominate this territory. Professionalism now becomes the
synonym for guild monopoly. Restrictions on entry to the profession,
exams, licensing, these are not intended to maintain quality, the school
argued, but to restrict the number of practitioners. And why restrict
them? Obviously, so that those already inside would be able to protect
and raise their incomes.

Self-regulation was a sham, variations on the fox guarding the chicken
coop. Physicians in this school had only one goal: Protect their own and
advance their own financial interests.

Well, those two rival schools, if you will, one succeeding the other, as
you look at this over the past 10, 15 years, the wheel of interpretation
has turned again, not all the way back to Parsons but quite close.

Professionalism now has become the best hope for resisting the demands
of managed care or any profit-seeking managers and auditors. The patient
is to be represented and stood up for by the doctor. Indeed, because the
government was not only a payer but the payer, professionalism had to
resist its intrusions as well. And as I think everybody in this room
recognizes, we\'ve had a fabulously intense revival of professionalism
and we are almost back in the days of Parsons.

So two important findings. I think I want to draw your attention to this
little anecdotal survey: One, there is no single historical line of
interpretation that will resolve the question of whether past crises are
more severe than current ones. You know, whichever frame you prefer you
may adopt, you can emphasize, you can stress. But there is no one line
of interpretation that will enable you to say \"Back then, it was so
good. Now, it is\" --- don\'t go down that road, I would urge you. There
is really no way of saying whether the profession has deteriorated in
its performance, whether doctors are or are not less committed.

Second, in the case of my own organization, we found ourselves after we
went round the wheel abandoning the issue, trying not to resolve the
past record, but defining ourselves in terms of future action. We take
as our fundamental challenge, leaving aside this historical context that
I provided you with, our fundamental challenge: What is the role for
professionalism in the 21st Century? Going forward, what does it mean to
make professionalism a force for change?

Clearly, the practice of medicine is different today than it was 50
years ago. It\'s different in what it can do. It\'s different in what it
should do in terms of best practices, fundamental differences in who
does it, differences in practice conditions, and differences in
reimbursements.

The assignment then becomes, given these changes, what do we do to
enhance, promote, use professionalism as the guide for action? What
considerations, whether in medical education --- which you\'ll hear from
later today --- in medical practice, in physician\'s behavior, in health
policy, what difference should professionalism make? And in the time I
have with you this morning, I\'d like to begin to suggest some answers
to that question.

I\'ve avoided until now, but it\'s not a serious issue, the definition
of what we mean by professionalism. Perhaps surprisingly, although not
in a room like this, there\'s a good deal of agreement on just what its
attributes are: Altruism and commitment to patients\' interests, the
starting point for everyone; profession as self-regulating, clear to
everyone; the obligation to maintain technical competence, again clear
to everyone; civic engagement, which I\'ll only say a word or two about
in a moment, a little bit more controversial. But there are those of us,
and I think you\'ve heard from them, too, over the past several years
who would put civic engagement in there as one of the attributes of the
profession.

I\'m going to come back to the key altruism point. But I want to begin
with the others because the altruism and commitment to patients\'
interests is so important and so complicated, if we begin there, I\'m
afraid we won\'t get out.

Professionalism\'s commitment to self-regulation. The historical record
is weak. If I was going to more aggressive, I could say pitiful.

The tradition of passing on troublesome colleagues to the next
institution. Every major institution that I know of and have been
affiliated with is totally scrupulous in terms of who gets to practice
medicine under its umbrella. I mean, you know, I know this. I experience
it. And if there are lesser physicians in terms of talent, etcetera,
etcetera, you know, a friend is going to go there, I will be told
immediately, \"Uh-uh, not there. You go here. Thank you.\"

As institutions, we are terrific at monitoring the capacity and quality
of our fellow practitioners. The problem though is that our loyalties
are very institution-bound, and we have no difficulty often in passing
on colleagues that we would not send our relatives to to the next
institution. Periodically, scandals will break out, and New York has had
its share. We don\'t do a very good job outside of our own turf.

Failure to police activities. We just came off a fabulous scam in
whole-body scans. Right? I mean, a useless, expensive,
anything-but-evidence-based procedure, although it collects a good ---
collected, I\'m happy I can use the past tense. I mean, obviously the
major professional societies did, you know, in the radiology world say
uh-uh. But very, very little concerted action taken to really put an end
to this. I mean, you know, let a scam come up. You don\'t see a lot of
organized action to take it down.

Anti-aging clinics, cosmetic claims, the anti-aging claims. Manhattan
has several. I\'m sure Florida, Arizona, California beat us by the many.
It is a scam. Many of us in this room have a real stake in anti-aging
claims would that they were valid. But I think most of us in this room
would suggest that giving 75-year-old men heavy doses of testosterone
might not be the thing you want to do. And we\'ve learned, despite all
the complexity, etcetera, etcetera, giving 65-year-old women estrogen is
not the thing to do. Growth hormone --- I mean, you know the litany.

And yet you can walk on the East Side of Manhattan as well as in these
other states, and there they are. There\'s even now an anti-aging --- I
don\'t know. I think they call themselves that. It\'s not recognized by
the G and E world. But there it is in medicine\'s record, so to speak,
and taking these things down is not very great.

Maintenance of technical competence, reducing medical error. There the
profession has done a more credible job. But the challenges it faces are
going to be quite extraordinary. The chart which was once thought of as,
if you will, in private practice belonging to the doc, if not, in
institutions, making the chart transparent, the use of information
technology; sharing data, somebody looking over your shoulder;
recertification --- I think many of you in the room will know the
stories of what happened of when the ABIM tried to put in
recertification --- resistance, but it may yet come through. The younger
generation is perfectly comfortable with it; and the evidence-based
medicine debates, which are quite fierce.

I\'ve just finished reviewing Jerome Groupman\'s book. The reviews
didn\'t talk about this, but I certainly do. It\'s a polemic in a
variety of ways against evidence-based medicine. It\'s going to ruin the
clinical intuition, and he comes out very, very strongly against it. He
was worrying about clinical insight. Many others, of course, worry about
the failure to do what ought to be done, whether it\'s the use of
beta-blockers or, you know, other interventions. A major area, and one I
think that\'s going to see enormous amount of activity.

I won\'t spend much time on civic engagement except that the data is
overwhelming that physicians do not participate in community affairs,
and I\'m allowed to say, even pediatricians who lead the pack don\'t
lead it by a lot.

You don\'t find physicians participating often in public discussions.
It\'s a much more reclusive profession except for many of its
professional medical associations. But most of them spend their lobbying
money on protecting members\' interests. They are member-interest driven
rather than advocating for the public good. This is not always true.
Pediatrics, some of the medicine groups can escape it.

In the *New England Journal of Medicine* piece that is in your packet, I
said something which brought me more shouts and screams than most things
that I say. I was dealing with this question of advocating for more than
pocketbook interests. And there\'s a quip in there, \"would that
ophthalmologists rather than GI guys advocated for colonoscopy.\" Well,
I mean, I meant it in just this frame. You can\'t imagine the invective
that I got. Don\'t you know the difference between an eye --- you know,
you can fill in the rest.

I was tempted to remind some of my writers that ophthalmologists to the
best of my knowledge had received MD degrees and might be perfectly
competent to review colonoscopy-funding decisions. But what I was trying
to do was to get out of the box. It was not a particularly
well-appreciated line.

Let\'s come to the core issue, altruism and commitment to patients\'
interests: money versus medicine, the HMO/hospital/group
practice/financial incentives, the drug company gifts and payments. I
mean, I\'ve already given you a frame that says it ain\'t quite as new
as some of those who worry about this may believe, but it is certainly
hot on the public agenda.

I use this slide for a purpose, and it\'s not simply to wake up a sleepy
audience, which is not this. A physician: \"Try this. I just bought a
hundred shares.\" All right, now this appeared in *The New Yorker* about
a year and a half ago if I remember. I don\'t want to spend a lot of
time deconstructing it. But just do the thought process of the
presumptions among those who edit *The New Yorker* and its readers, you
know, that this will be understood, will be seen as funny. This builds
on a lot of assumptions that suggest that ultimately the professional is
really money-driven. Parsons notwithstanding, this is what it\'s about.
That this is seen as understandable and humorous suggests a quite jaded
public view of exactly what\'s going on.

This slide comes from *The* *New York Times* as you see. On the weekend,
she\'s a cheerleader. During the week, she\'s a drug rep. When I\'m
lecturing the medical students, I remind them that once upon a time in
the \'60s and \'70s --- Dr. Pellegrino will probably agree --- the
anatomy course would, you know, throw in pictures like this even a
little racier to wake up students. Now we\'re at \'05. And, again, what
does this say about the profession to the public?

I will share quickly a humorous story. I had been doing some work in
China on issues of professionalism. They were interested in it for a
variety of reasons, and I sent this slide. And then I had some second
thoughts about it, did I really want a Chinese audience to deal with
this? And I wrote to the convener of the meeting and said, \"Look, take
that slide out.\" And he e-mailed me back very quickly, \"Yes. We will
take this slide out and we\'re delighted that you made this decision.
Our translators couldn\'t figure out what a postage-stamp skirt was,\"
the dangers of doing cross-cultural work.

*(Laughter.)*

The press coverage. For a project that I\'ll tell you a little bit about
later, we had one of our researchers just cover the press, you know,
over July, the extent of it, a lot of it in *The Times*, a lot of it in
*The Journal*. But it goes out to *The San Jose Mercury News*, \"Science
critics \... Financial Ties\", \"Financial Ties to Industry \...\",
\"Hospital Chiefs Get Paid for Advice on Selling to Hospitals,\"
\"Indictment of Doctor Tests Drug Marketing Rules.\" I mean, again, it
goes on, \"\... Conflicted Medical Journals.\" Look, this is the reading
public. A week? You know, I keep a pretty extensive file. There can\'t
be a week when I don\'t add to it on conflict of interest, and it\'s
almost every day between *The Wall Street Journal*, *The New York Times,
The L.A. Times, The Philadelphia Inquirer*.

Many of these reporters, by the way, are not in the health section but
in the business section. So the public is getting a pretty steady
accounting of conflict of interest, and it\'s very, very much on the
public mind.

It was knowing this that the ABIM Foundation, at that point in time
headed by Harry Kimball, and my organization got together to see what we
might want to say about conflict of interest questions given their
extraordinary prominence. In the room is one of my colleagues who worked
on this, Susan Chimonas. You\'ll be hearing later from Jordy Cohen. You
know many of the other names on here from Troy Brennan to Neil Smelser,
Jerry Kassirer. I mean, you know these people.

We spent several years, two to three, doing this piece and found our
task --- well, we found two things. One, we had to create, so to speak,
a table of contents which I\'ll show you in a moment. What were the
major issues that ought to be on the table? And simultaneously we really
tried to give an account of what we thought should be done. You know,
what are our recommendations to deal with these issues?

I will say here that the group began very moderate in its posture. Given
my training, I would call them, if you will, moderate abolitionists,
gradual abolitionists, don\'t move too fast.

The more the group stayed with the issue and the more the analysis went
on both in terms of information about the practice, the impacts of these
various practices and our own sense of what should be done, we became,
if you will, Garrisonians, immediate abolitionists.

And this is a fairly consistent, if you will, abolition document. It\'s
had, I mean from our perspective, a wonderful more neutrally-put
extensive impact, maybe even more because we set out the table of
contents in the left-hand column, the activity that, you know, we
worried about. I mean, the left-hand column has now become, if you will,
the checklist as more and more institutions review their own policies on
conflict of interest.

We limited ourselves incidentally to academic medical centers because we
could find no easy way to influence community physicians. That seemed
beyond us. But at least academic medical centers, centers which did all
the training, centers of influence, there we could speak to them.

Gifts, meals --- eliminate. You can read this. Samples --- indirect, not
in the doctor\'s office. Speakers\' bureaus and ghostwriting --- I mean,
scandalous. The ghostwriting, it\'s hard to imagine anybody accepting
this. This is what we throw kids out of college for. I mean, where we
come from, it\'s plagiarism or something of that sort.

Speakers\' bureaus --- we\'re not talking about honoraria. That\'s a
separate list. We\'re talking about joining the speakers\' bureaus and
becoming the hired hand of the drug company --- shill, commercial sex
work, I don\'t know what terms you want to use --- infamous. And there
we had no problem saying eliminate.

Payments --- okay, but get it out of direct support for CME, get it out.
Don\'t let the division chief or the chairman pick up the phone to call
the drug company to say, \"I need \$20,000 for\...,\" that sort of
thing.

Consulting, honoraria, and research contracts --- we did not say no. I
mean, we recognize fully well that, if you will, pharmaceutical
companies are not tobacco companies. We appreciate that. You can\'t end
all the nature of the relationship. And the cheap shots that were taken
at us were, \"You\'re demonizing the pharmaceutical company.\" We\'re
not trying to demonize the pharmaceutical company. We were trying to
eliminate as far as we could conflict of interest in this arena.

Consulting, speaking honoraria, and research contracts have to be
maintained. But we do ask for transparency, but real transparency.
Specify the terms of the service, make them available for public
inspection, let it be known how much. You know, you\'ll see the
disclosures in journals. Consultant to X drug company --- \$100, \$500,
or \$500,000? It does make a difference, and that urge on our part to
render it transparent we think is crucial.

Formulary and other purchasing decisions --- decision-makers must be
conflict-free.

After the appearance of that article, I received a phone call from Pew
Charitable Trusts who read the piece, saw the press coverage of it which
was extensive, and then asked an embarrassing question: What did your
committee think to do the week after the report was released?

Our committee in truth, as I told them, had not spent five minutes on
what we would do after the release. Here\'s our view, but, I mean, we
spent not a moment on what we might think about in terms of
implementation. Pew Charitable Trusts is many things, but it\'s not the
IRS. So when it says, \"Think about it, and we\'ll help you,\" we were
prepared to start thinking about it and we did.

The prescription project funded handsomely by Pew is working in a
variety of areas, the two areas most central to our conversation today
and really most central to the project, to see what we can do to change
conflict of interest policies at academic medical centers.

There are some lead groups out there: Stanford, Yale, Penn --- you\'ll
read tomorrow about BU --- Wisconsin, Michigan, Kaiser. It means a lot
of forward action. The wind is to our back and we\'ll see what we can do
in that territory --- translate prescriptions into practice and the very
same thing with professional medical societies.

I give you this and tell you this background to it because you are
obviously quintessentially in the formulation area. It was unusual for
us --- we were not prepared for it --- but we are finding it very
exciting to look at actually changing practice in an area that we have
been studying.

Where do we go from here? I worry. I worry a lot about professionalism
lite. I hear a lot about this. I get anxious when professionalism gets
equated or swallowed up by good manners. Look, good manners are very,
very important. I don\'t want to discount them in people or in doctors.
But that\'s not the sum and substance of professionalism.

Humanism is important. Look, I come out of the social sciences and
humanities, not out of medicine. And, you know, the humanistic spirit,
god knows, is important. Again, I don\'t want to

--- you know, I think it\'s important that medical students read
literature, although I will tell you as you already know and can
remember, there are professors of literature that I would no more trust
to be good-mannered or acting in my best interest than anybody else. But
humanism is important, but they are not substitutes for substance.

My last slide is probably my most controversial slide. Professionalism
lite is easy to put down. At least, I think it\'s easy. I think it\'s
really important to talk about what it really means to advocate for
professionalism.

Put patients\' interests first, but don\'t coddle that. That really is
meaningful. Look, you may have to take a financial hit. That\'s what it
may mean. You know, speakers\' bureaus are fabulous. They\'ll send you
to Hawaii and they\'ll pay you X-teen thousand.

One dean has mentioned to me that as he put in a ban on this sort of
activity an angry colleague came up to him and said, \"You are now
depriving my children of their college education.\" Okay? I mean,
rhetoric, not rhetoric? I don\'t know. But you certainly can get the
heat up. If you mean it, this is what it means. You know, if you\'re
really going to talk about it, this is what it means.

Technical competence? Sure. But it means you\'re going to have to let
people look over your shoulder. None of us like having people look over
our shoulder. That\'s not the most pleasant activity, but that\'s what
it really means.

Self-regulation. You\'re going to have to say something. From my
context, you know, the guy who is handing out testosterone, you know,
like it\'s life-savers, do something. Report a colleague. It\'s not
comfortable. None of these are comfortable. But ultimately I think
they\'re crucial.

The last slide, you know, the last bullet, physicians will campaign for
public benefits, not private reimbursement. Change the orientation of
professional societies. Members may not like it, but that may simply
make the issues all the more important.

Thank you for listening. I\'ve enjoyed the chance to present, and I look
forward to the discussion.

CHAIRMAN PELLEGRINO: Thank you very much, Dr. Rothman. Dr. Dan Foster, a
member of the Council, has graciously agreed to open the discussion.
Dan?

DR. FOSTER: I didn\'t really agree. I was just told to do it.

*(Laughter.)*

CHAIRMAN PELLEGRINO: But you were told graciously.

DR. FOSTER: Well, I think that, I mean, there are many things that one
could comment on in the report and very little that I think that I would
disagree with.

The first comment I want to make is that the good old days of all-white
males are completely gone in most academic centers, I\'m sure. I was at
Columbia not too long ago. White males are an endangered species in
medicine. We have 55 new interns and four are white men. I mean, it goes
back.

There are no, almost no, white males going into medicine anymore and for
complicated reasons. There are many women and, of course, a huge number
are of second-generation persons from Oriental and other things. But
that one, we don\'t have to worry about anymore.

Secondly, the traditional views of professionalism, as you pointed out,
go back a very long time and were much narrower than the social issues
that you have talked about here.

Osler in 1902 gave a great talk in which he started off --- he had four
things to say about medicine and what it should be. He said it had a
noble heritage, that there was a long line of true physicians that went
back to the founders like Maimonides and Hippocrates and so forth, and
that he was asking the guild, as he called it at the time, to take their
place at the end of this long noble line. He believed that it was a
noble profession. And if you go back and read the history, that term
\"noble\" enters very often.

Secondly, he said that it had a remarkable solidarity to track to their
sources the causes of disease and to make these new findings available
to everyone. It was not a solidarity of race or sex or political
meaning. It was to fight disease. It was to prevent premature death and
cure disease when that was possible, that it was to alleviate symptoms
when cure was not possible. It was to comfort always the priestly
function.

Third, he said it had a progressive character. In his day, they were
shifting from magic to science, and they did it. They made that change.
That meant that one was a life student. It has to do with your issue of
technical competence, which is not easy. I\'ll comment in just a second.

And, finally, he said, it had a singular beneficence. He said the relief
of human suffering was such to make the angels sing. We don\'t talk like
that anymore. But this was the core of professionalism in Osler\'s view,
and I think that still holds very much.

The technical issues are not solved by evidence-based medicine. One of
the real problems is that you have very good studies by very good people
who come to different conclusions. For a long time, we believed that
estrogen replacement would be helpful in terms of heart failure and so
forth in women. Everybody agrees that this was a solid
statistically-wonderful study, and then it changes. And they change in
different parts of the country, so it\'s not --- and then you worry
about a challenge to the nature of journals that 35 percent of their
statistical analyses were no good and they didn\'t believe it, and they
reproduced this from the Spanish statisticians that challenged it, and
it turned out it was true.

So oftentimes the --- and the meta-analyses that everybody pays
attention to about, you know, whether this --- I think most scientists
are really skeptical about that because you don\'t know. You\'re giving
equal comment to studies of all sorts of things, old people versus young
people, all sorts of things of that sort, so it\'s a problem.

And then in the traditional sense, Joe Goldstein in his last career
award --- I can\'t remember whether I mentioned this before sometime.
But in 2004 --- and I didn\'t check it --- there were 550,000 papers
published in the biomedical literature in the 4,000 journals that the
National Library of Medicine archives in PubMed and so forth.

550,000 --- that\'s more than a paper a minute. Now let\'s say that only
one of 1,000, Goldstein said, if only 1 of 1,000 is important, that\'s
still 500 major papers that a practitioner and a scientist has to keep
up with to do it, and that has nothing to do with this issue of somebody
looking over and what best practices are. It\'s much more complicated
than that, I think, and much more difficult than to be dedicated to try
to learn those things.

And I think the last thing that I want to say is that it\'s very easy to
recommend to others that their income ought to go down. As Bud Relman
said last week, \"You can\'t go to any major city in the country and
find an internist for an aging patient.\" People won\'t take Medicare
anymore. They don\'t follow their Medicare patients, because their
income goes down.

I have a son who is a general internist, and he\'s very good. He admits
his own patients to Baylor Hospital and so forth, and he has a wonderful
group. His income has gone down every year for the last four years. And
he doesn\'t do anything shady. I mean, he doesn\'t give Botox or
anything like that.

But I\'m not talking about big money. I mean, there are some people that
make big money. I\'m talking about trying to make \$100,000 a year as a
general internist. I get \$40 for seeing them. I\'m a professor, but I
get \$40 for seeing a patient for Medicare. We still see them. was
addressing a bunch of doctors at one time. Internists are very
demoralized these days because of these changes in money and so forth
and the fact that it goes on here. And we had taken our dog to the
veterinarian, two dogs we took for a bath and shots. And it was \$250
cash upfront. And I get paid months later \$40 for seeing a patient.

So there\'s a worry about that. And then to say, \"Well, you\'re going
to have to take a hit financially if you\'re honorable\" --- that\'s
sort of what it says. And that\'s probably true.

But that\'s very easy to say when you\'re not --- and I\'m not speaking
about you at all, you understand. But it\'s very hard to find people to
even go into general internal medicine anymore to get people who will
take care of real patients, not subspecialty.

And the last thing I would say is that I don\'t think --- I know you\'re
not attacking drug companies. But almost everything that happens, one
has to look for somebody who must have some interest to give significant
money.

I\'m the president of the Academy of Medicine, Engineering, and Science
in Texas. That\'s all the people who are members of the national
academies that live in Texas. And in response to the gathering storm
report of the National Academy about the failure of their --- there\'s a
great editorial in *Science* this week about stem and so forth.

But we took on at the request of Senator Kay Bailey Hutchinson, our
senior senator, the Academy is going to study the teaching of math,
science, and technology in the Texas schools. This academy has no money,
I mean, really. I mean, the university presidents give us about
\$250,000 total a year, you know, to keep up with.

So we have to say, this is a very great thing to do. How are you going
to do it? Well, the first gift we got was from Dow Chemical. They
didn\'t put any --- they just said, \"We\'re very interested in this\"
and so forth. But everything that you want to try to do, you have to
have somebody that\'s got some sort of an interest unless they\'re
purely altruistic that they just want to give money. And the pressure
from their stockholders is very hard, you know, if you\'re going to give
a lot of money to support the study of Texas schools.

So, I guess I\'m a little worried about the idea that the involvement of
big businesses and so forth has to be always completely pure without any
interest. I mean, nobody in the government does anything without some
interest that they have, and I think we have to be careful about the
terrible things that your group on professionalism has said.

But I think it\'s going to be a little hard to say, \"Well, we can\'t
receive.\" There\'s always an implication that nobody gives money unless
they have a self-interest. Well, if you give money to the symphony in
Dallas, you have a self-interest because people will think American
Airlines is good if that do that and so forth. But, anyway, I think
it\'s a terrific thing here.

The last thing I would say is that I think it\'s hard to teach ethics or
to teach professionalism by papers or by lectures. There\'s a statement
that I gave that I found that I thought was very interesting, and it was
about the contract between teachers and students, what do they owe each
other? This person who writes about this a lot said, \"Great teachers
don\'t teach. They help students to learn.\" That\'s a profound
statement. \"Great teachers do not give lectures,\" he says. \"Great
teachers do not teach. They help students to learn.\"

It seems to me most of the time the lessons of individual
professionalisms of the Osler type and so forth almost always occur
because of a role-model who is professional and where they see.

So I\'m fairly skeptical about the --- I think it\'s good to get a
structure of what ethics means and so forth, and probably somebody
should have a lecture of that. But I don\'t think we\'re going to
transform people to working in the public interest and so forth, let\'s
say, for health unless there are people who do it that a student can
identify with. So I\'m not sure that one can teach in a didactic sense
what professionalism is about.

So I think this is a wonderful effort that one has made. But I think
that one has to be --- and maybe the prescription thing is an excellent
way to go. I mean, I don\'t know. But I think it\'s really, really hard,
and I wouldn\'t want to think that it\'s a simple thing to deal with,
and I know that you don\'t think that because you do this all the time.
I don\'t do it at all, but, I mean, except that --- I would say I don\'t
want to sound self-serving. But I do try to show it, you know, on the
wards and so forth.

And I\'ve been very active in public. I ran for the Presbyterian Church
all the inner-city work for four years in Dallas, Texas. I\'ve been
involved in all these things, so I\'m not being critical about it. But
you have to be motivated to want to do that, I mean.

I rented the Dallas Auditorium for the first Martin Luther King
celebration without permission from the Church. I thought I was going to
get ex-communicated, but they actually thought it was a nice thing to
do. So you just have to have a model. I served on the Dallas School
Board. I was a trustee during the desegregation case. But you have to
have somebody who does this that says, \"Well, maybe I could do this.\"

And the last thing I\'d say, I\'m very touched by the AIDS work that a
drug company is sponsoring in South Africa and Africa where all these
young physicians --- I think there are 50 or 60 now --- that are sent
there for two years. I have a bunch, a number, that are over there. They
are paying their salaries. They\'re building the clinics. And these
young people, these young people where they\'re right in the middle of
their careers, you know, that haven\'t finished their fellowships and so
forth, are giving two years of their --- and so you see these sorts of
things. Now they\'re an inspiration to me to do that.

I didn\'t mean to talk so long about this, but it\'s something that I
feel very strongly about. And as I say, I think that it\'s going to be
hard to universalize this and I think it\'s going to be awfully hard to
get people to say, \"Well, I\'m going to cut my salary\" when nobody
else does it. I think that\'s going to be hard.

CHAIRMAN PELLEGRINO: Thank you very much, Dan. Dr. Rothman, did you want
to make a brief ---

PROF. ROTHMAN: I think it would be more helpful to hear the others.

CHAIRMAN PELLEGRINO: Very good. Thank you.

DR. CARSON: I identify very, very strongly with Dan\'s comments.
They\'re right on target. You know, I\'ve spent my entire career in
academic medicine where there has not been as much of a drive to enhance
one\'s income. Sort of automatically, one takes the altruistic road when
one decides to go into academic medicine. Nevertheless, those people
that do still have pressures.

I\'m reminded of the story of the neurosurgeon who had some plumbing
work done at his house and the plumber gave him the bill, and it was
\$2700. He said, \"\$2700? I\'m a neurosurgeon. I don\'t make that
much,\" and the plumber said, \"I didn\'t make that much either when I
was a neurosurgeon.\"

*(Laughter.)*

But, you know, the fact of the matter is that there always has been sort
of this feeling that doctors make too much money. It may even stem back
from when people were in grade school. You know, people who went on to
become doctors were always the ones who sort of changed the curve and
made you get a bad grade and, you know, people feel resentful of those
kinds of individuals.

But one has to take into consideration the enormous amount of money that
it takes to pursue a medical career. I was talking to a fourth-year
student not long ago, a medical student. I said, \"What\'s your debt up
to?\" He said, \"\$300,000,\" you know, when you still have internship
and residency to go through and you\'re not going to be paid very much
money during that time and all of your friends who have gotten their
MBAs and their legal degrees are, you know, leagues ahead of you, and
then you get into the profession and people say, \"You shouldn\'t make
any money. You should be a good guy,\" you know, that doesn\'t compute.

So, you know, we need to actually address those issues rather than just,
you know, making little platitudinous statements about you guys ought to
not really be interested in a financial remuneration.

CHAIRMAN PELLEGRINO: I have Dr. Hurlbut and Dr. Meilaender after him.

DR. HURLBUT: So you articulated certain dimensions of the problem well,
but I want to explore something that\'s implicit in what you were
saying.

In the first comment you made, you spoke of the dominant culture that
governed medicine in the past, and it wasn\'t really the good old days
only. I mean, obviously if the physicians are all male, white, and
upper-middle class it indicates a lack of opportunity for some people,
but also perhaps more seriously a kind of limited perspective engaged in
the practice of medicine, a kind of prevailing culture.

And so basically what I want to ask you is, what limitations are subtly
and maybe unconsciously being imposed by today\'s prevailing culture?
And just to unpack that a little, we are, at least by some critics, a
materialistic consumer-driven society. Maybe that\'s influencing
physician\'s values and their codes of conduct and self-justifications
as you\'ve said.

But could it also be that there are some other dimensions? You mentioned
enhancement technologies. Without really giving much articulation to it,
you dismissed some practices that physicians do as being not
physicianly.

So what I\'d just like to get at is, what do you think the role of the
physician really is? What are our purposes? What are the limits of our
prerogative? And what kind of service are you really calling us to be?

And I know that\'s a very big question and very broad, but just if you
could make some comments about what dimensions of the prevailing culture
might be perverting medicine today and how we might more specifically
articulate the professional role in the face of those.

MR. ROTHMAN: I know I promised Dr. Pellegrino that I wouldn\'t comment
until all, but your question is so specific so I\'ll address it. It\'s a
truly wonderful question. I won\'t comment on the first part of it, but
I promise you the next time I get to talk about that I will.

What did it mean? What did it mean that it was an all-male, all-white,
upper-middle class profession? That\'s a great question. And there are
things that it did mean, but we\'ll save that for another time given the
limits of time here.

But your second question --- and it\'s actually helpful given the
comments, you know, that came before you. I\'ll give two examples.
Remember in the old days, you know, in the rationing debate when Oregon
did its rationing scheme and it limited it to, you know, Medicaid
patients, many of us said, \"When it comes to rationing, it\'s really
easy to ration the other guy\'s medical care.\" Right? I can tomorrow
ration Medicaid. Right? But, you know, if you\'re going to start
rationing my medical care, etcetera, etcetera.

And I was not intending to have physicians take a vow of poverty. You
know, that\'s not my theme, and your question enables it. What do you
think the problems are? I\'ll give you two examples from *The New York
Times* --- but then please respond back --- a story within the past
week.

It will take you approximately --- don\'t hold me to the exact numbers.
It will take you 30 days to get a dermatologist, the *Times* wrote, to
take off a suspicious-looking wart to see if that wart is cancerous. It
will take you four days to get Botox. Okay? Something\'s wrong.

Now this is not a vow of poverty, and I\'m not trying to do a number on
dermatologists. But there\'s something going on that you can get your
Botox --- and we know what\'s going on. Dr. Foster, your comments. You
think it\'s hard to get into medical school? Try to get your kids into
veterinary school. I mean, the word is out. I mean, you know, people
understand this. The plumbers aren\'t lining up quite so much. That\'s
humor. It\'s not real. But the vets are real. So a profession in which
you get Botox quicker than you can get a biopsy.

A story about a year ago of a guy coming out of oncology who
self-reported, you know, was making \$300,000 or \$400,000 goes to
Goldman Sachs, works for Goldman Sachs and now is making, you know,
\$3,000,000 to \$5,000,000, I mean, and was quite proud of it by the bye
and when asked whether he felt any twinges, etcetera, etcetera, he said,
\"No. Sooner rather than later I\'ll become a philanthropist.\"

So the question is, you know, it\'s not a vow of poverty. Nobody
intended that, although I will also just add parenthetically until the
middle \'60s the profession was not particularly well-paid. Then
procedures and Medicare came in and changed the income distribution,
procedures particularly by detaching reimbursement from time. That\'s
really another subject.

But it\'s a profession. And the meaning of the profession taught,
modeled --- I have no problems with that --- somehow or another
communicated. Jordy Cohen will be talking about medical education in a
little bit.

You know, Botox is really neat. But, you know, biopsy first. That kind
of message. I\'m not saying --- you know, if you want to run a little
thing on the side to make some money, all right. But don\'t bump biopsy
for Botox. It\'s like a car sticker. Right? Don\'t bump biopsies for
Botox, somehow or other by modeling, by freeing medicine up from the
more obviously marketing ploys, from trying to give a sense of value
that this is not a marketplace activity.

But please respond back.

DR. FOSTER: Let me just make one comment in the Botox thing. What\'s
wrong with that article is that the Botox is done by technicians and not
by the doctor, and so it\'s very easy for them to just schedule somebody
to come in. You know, you don\'t even have to be an MD to give Botox. At
least in Texas, you don\'t.

So I think one of the problems is that you have a physician assistant or
somebody who can do things faster and that may be one of the reasons.
I\'m sure it\'s money. Don\'t misunderstand.

PROF. ROTHMAN: The *Times* piece didn\'t draw that distinction. I don\'t
know if it was in their story.

DR. HURLBUT: What I\'m really getting at is --- I mean, you\'ve partly
answered this --- what you might call prevailing cultural values.
They\'re almost unconscious to the culture. It\'s so close to you that
you can\'t see it.

PROF. ROTHMAN: Yes, yes.

DR. HURLBUT: And here I\'m thinking of things like the emphasis on
autonomy and individuality that prevails in our culture, the sense that
there\'s a new relationship, not patient/doctor but client/provider,
where we\'re serving the patient\'s aspirations and ambitions and not
necessarily more profoundly articulated purposes and values.

Just to give two very obvious and extreme examples, physicians have been
expected to become executioners at death penalties and in some cases
implicitly expected to serve patients\' personal desires for
gender-selection abortions. And so I\'d like you to comment a little on
this.

These are worrisome things because if the physician\'s role is
socially-constructed and socially-defined, then are we somehow in need
of a deeper root, both intellectually and specifically articulated in
our code of conduct?

It seems to me that physicians are in danger of becoming agents, not
just of individual patient\'s desires, but of larger unarticulated
purposes of the society as a whole including almost becoming tacit
social scientists and engineers for the kind of society that we want to
get and, strangely, even ultimate authorities on matters of what defines
personal responsibility, what defines acceptable species\' conduct, what
even defines human purpose.

These are really new roles for the physician, it seems to me, and it
seems a lot of this is very unconscious. A lot of it is just our not
being aware enough of how we as a society are actually imposing certain
values onto medicine itself.

PROF. ROTHMAN: But then --- and just a response, because there\'s so
much more, but these are fabulous points.

I taught a couple of years ago with a colleague in the law school. We
taught a course to law students and medical students. And I don\'t mean
this as a putdown of lawyers. The lawyers really define themselves as
client-driven. Hired guns is not, you know, etcetera, etcetera. The
medical students to their credit were much, much more conscious --- I
mean, they could go overboard, too --- much more conscious of the fact
that, although they had duties, they also had professional obligations.

I mean, the gorgeous case that you raised: The AMA to its credit and
others not allowing for the physician participation in capital
punishment. It\'s a very --- I mean, that was well-done. You are not the
handmaiden of the criminal justice system. The criminal justice system
may decide to do capital punishment. You, as physicians, don\'t belong
there. And that was done and said very, very well. You\'re not the hired
guns.

I mean, yes, I know. And this notion of physician-patient partnership, I
have a lot of difficulty with that. I mean, I didn\'t go to medical
school. I hope my doctor went to medical school. I don\'t want to deal
with all the stuff that he knows. I don\'t have to find that out. It\'s
a complicated relationship.

But you\'re not a hired gun, and I think that has another aspect of
professionalism. Indeed, it\'s what, you know, I think in many ways
drove Soros and others to say, \"The state doesn\'t control you.\" The
government says, you know, a gag rule on abortion discussions. Medicine
got its back up. We\'re not here to take orders on what we say to our
patients. We\'re not here to be servants in your criminal justice
system. We have an ethic and an ethos apart from the society.

Now it\'s tricky and hard to teach it, and it\'s tricky and hard to
model it. But you\'re really at what I think are core issues of
professionalism.

CHAIRMAN PELLEGRINO: We have Dr. Meilaender, Dr. Dresser, Dr. Kass, and
Dr. George. And before you launch into your comments, thank you. We\'ll
start with Dr. Meilaender.

PROF. MEILAENDER: Yes. I\'m not sure whether this is a question or a
comment, but I\'ve been trying to think about sort of what a body like
this is to make of your presentation.

And for me at least, I\'m more persuaded by certain examples. That is to
say, when you\'re lower to the ground and you give an example of a
particular conflict of interest or something, I\'m more persuaded by
that than by the theory of professionalism which seems to me to need ---
I don\'t know --- to need work in a lot of ways. I\'ll just tick them
off. I won\'t try to defend them at length right now.

But it\'s not clear to me why a professional, simply because he or she
is a professional, is to be civically engaged. There may be other
reasons why they should, but. Nor is it clear to me why I should pay
particular attention to them when they\'re civically engaged just
because they have professional expertise. That\'s one sort of thing.

Second, putting patient interest first --- and this relates to Bill
Hurlbut\'s comment --- I mean, this needs a lot of sorting out. By
patient interest, do we mean patient\'s desires? Do we mean the good of
the patient? The health of the patient? Patient interest covers a whole
range of sorts of things there and, in fact, blurs some important
arguments that it seems to me need to be made.

And then third, and sort of most importantly and most central to your
presentation on the issue of altruism --- I mean, Dan Foster said
everybody has interests. I think that\'s true. We need a lot more work
on what we mean by \"altruism\" if this is to be theoretically helpful,
it seems to me. You don\'t want people who lack interests. That would be
to lack projects in life, sort of. Nor is it necessarily a bad thing if
my interest and the interest of the others should coincide in various
ways. I mean, this is not a bad thing. So whatever altruism means, it
doesn\'t mean the obliteration of self-interest, at least I\'d like to
see the theory worked out that persuasively argued that. I doubt if it
can be done.

So at the theoretical level, it seems to me --- I\'m just not sure ---
I\'m not entirely persuaded and I\'m not sure kind of where to go though
a lot of your particular examples seem to me, you know, fairly
persuasive.

CHAIRMAN PELLEGRINO: Dr. Dresser?

PROF. DRESSER: Thank you. I really liked the JAMA article because it
went beyond hand-wringing and really some, I think, concrete and
reasonable recommendations.

I wondered if you had thought much about the internal challenges in
academic medicine to being a good professional. I see my colleagues at
the medical school torn in a million directions. Should I spend more
time teaching with students? Should I see more patients? Should I spend
more time in the lab and on research and getting published? And to me
those conflicts really certainly affect patients and students and the
contribution to knowledge.

So in some ways it seems to me at least the academic medical profession
needs to think about, well, what does it mean to be an academic medical
professional today? Is everyone supposed to do everything? Are there
different classifications? Because it seems to me when I see so many
people trying to do everything and they\'re suffering and the patients
are suffering, I would hope that that could be a component of this work.

PROF. ROTHMAN: That\'s very interesting.

CHAIRMAN PELLEGRINO: Dr. Kass?

PROF. KASS: Thank you. This picks up, I think things that Gil and, to
some extent, Bill Hurlbut were saying.

I don\'t doubt for a moment the seriousness of the kinds of threats to
medicine as a profession that you\'ve identified here, but they mostly
seem to be the temptations connected with money and have to do really
with these external matters that tend to corrupt.

And it seems to me the emphasis on professionalism, which I find an
extraction and not terribly helpful, quite frankly, gets to be defined
as the opposite of the trade because the problem seems to be the
corruption that the trade element introduces into what it is you think
should be going on and, therefore, the language of interests as opposed
to altruism seems to come out to the center. Are you serving your own
self-interests defined in terms of being a tradesman rather than the
interests of your patients? And I think that\'s what sorts of skews the
presentation.

I don\'t think Hippocrates would have understood himself as a
professional. He would have understood himself as a healer. And it seems
to me --- I would be interested to know how one begins to think about
the special aspects of that kind of professing which is the activity of
healing and whether we worry slightly wrongly if we think simply about
the deformations that occur at the margins and don\'t think enough about
the positive definition of what it means to undertake the vocation of
being a healer, and that\'s to begin really not with some abstract
notions of profession and worry about the deformations and the
misconduct, but to talk about the professional formation concretely in
terms of what is this work, and we\'ll talk about it.

And Dr. Pellegrino\'s paper, I think for my money, comes a lot closer at
least to those internal questions of the character of the profession,
and I wonder whether you\'ve thought about those things which are
internal to medicine having nothing to do with money that are every bit
as much of a challenge to doing this work well as are these kinds of
deformations.

Dan Foster landed on one of them simply talking about what it really
means today to try to be technically competent. And a small piece of
that also is a drive towards specialization which isn\'t simply
money-driven, but it\'s very, very hard for anybody comprehensively to
serve the patient\'s well-being in this kind of age when so much is
needed.

And similarly with technology. I mean, we would not want to do without
some of these things notwithstanding the fact that their abuses are
commercially-driven.

So I\'m really wondering about the presentation of the model of a healer
in an age of hyper-specialization and massive increases of knowledge and
to not let go of the fundamental meaning of what it is to reach a hand
out and accept the reach for help on the part of someone who is ill and
wants your loyal service.

PROF. ROTHMAN: A quick question back to you, although the Chairman is
probably going to disallow it, but let me just do it very quickly.

There is a common ground. I mean, you know, how you deal with the
practice, how you deal with competence given these articles and, you
know, and the role, you know, given those numbers. That\'s been one of
the things that the evidence-based crowd says.

My problem with \"healer\" is that it individualizes. The term itself
seems to render the practice. It\'s not necessarily integral to it, but
it, so to speak, turns it back one-to-one. And those of us who worry
about the profession really want to think much, much more about --- I
hate to use this word and don\'t hold me to it much --- the collective
organized responsibilities that, in fact, the profession has
responsibilities.

\"Healer\" seems to put it --- and maybe you missed my reading of it, so
it\'s really a question back to you. \"Healer\" seems to put it back in
that kind of examine room one-on-one where those of us who are worried
about the profession are really thinking about organized collective
responsibilities, really as was being said. But you\'re smiling, so I
think I may have touched something, but I\'m not sure.

PROF. KASS: Mr. Chairman, can I have 30 seconds? If it\'s out of order,
tell me.

CHAIRMAN PELLEGRINO: No, go ahead.

PROF. KASS: No. Look, I don\'t deny that there are systemic things from
how medicine is paid for to how the professional societies organize
themselves that are important.

But it seems to me that if one wants to form physicians who understand
what it means to do the work, one has to really take absolutely
seriously that their work is encountered one-by-one and these other
things are constraints which sets the boundaries.

But how you model what it means to actually --- I mean, Hippocrates
says, \"I will apply dietetic measures for the benefit of the sick. I
will keep them from harm and injustice.\" And that\'s a kind of ---
that\'s a vocation. And without that, the rest of the stuff, it seems to
me, can\'t do the work.

CHAIRMAN PELLEGRINO: Thanks, Leon. I have Professor George and I also
have Dr. Carson, and then I think we\'ll give Dr. Rothman a chance to
respond.

We\'re going to be discussing this subject this afternoon, and I think
some of these questions will be recurrent and you\'ll have an
opportunity to discuss them in more extent. So Robbie?

PROF. GEORGE: Thank you, Ed.

Dr. Rothman, thank you for your presentation. I was impressed by your
wonderful moral passion and by the almost prophetic stance that your
organization takes toward holding physicians as professionals to very
high moral standards. We can debate, you know, whether they\'re the
right moral standards. But the idea, I gather, really is to hold people
to high standards.

Now, of course, that presupposes that we can know something about
morality. We can know something about the truth of these matters, about
moral truth which, of course, raises the question, how do we know such
things? And in questions of disputation among serious people, how do we
decide whether it\'s a good thing or a bad thing for doctors, for
example, to be involved in capital punishment?

Obviously, the decision has got to be made. It\'s a moral question. I
think you\'re presupposing that we have some way of knowing these moral
answers to these moral questions, so I\'m kind of curious about where
you and your organization come up with what you think the moral truth of
the matter is.

Secondly, I\'m impressed in the willingness of the organization, like
advocacy organizations across the spectrum irrespective of ideology,
right or left and so forth, to be willing to impose or see imposed on
people adherence to these norms. They\'re not just putting them forward
as optional. You want to see them imposed, like, for example, the norm
that I gather you would like to see imposed that has been imposed that
physicians may not participate in capital punishment.

So it\'s not just an ideal or a proposal to people. It\'s an imposition.
And physicians who would dissent from this, who would want to make a few
bucks or believe that they\'re doing a good thing and perhaps even
something that justice requires in participating in capital punishment,
they could lose their license to practice medicine or their standing if
they deviated from this. So obviously you don\'t have a problem with
norms, moral norms, being imposed on people.

But then where do we draw the line and why do we, why would you, for
example, have a problem with the government telling physicians that,
\"Look, we don\'t want you promoting abortions. We think that\'s a bad
thing, not a good thing. We\'ve made a moral judgment. If you do that,
you\'re violating what we think doctors ought to do, the moral norms
doctors ought to stand up to\"?

So obviously you don\'t think --- you\'re not a hypocrite. You don\'t
think it\'s all a question of whose ox is being gored. But how do you
handle those admittedly very difficult questions when it comes to
proposing the exercise of power to coerce people to conform to these
norms?

CHAIRMAN PELLEGRINO: Thank you. Dr. Carson?

DR. CARSON: I want to thank Dr. Rothman for that wonderful presentation
and for a willingness to try to take on such a big topic in such a small
period of time.

PROF. ROTHMAN: I do get to teach a course, literally ---

DR. CARSON: Basically, you need one.

PROF. ROTHMAN: --- on professionalism. But that\'s a semester you\'ve
been spared.

DR. CARSON: You know, I wonder in academic medical centers where the
breakdown of professionalism is in terms of individual clinicians versus
administrations, when it comes to advancement in academics because, you
know, having been in academic medicine for such a long time, I\'ve seen
an enormous number of absolutely top-notch clinicians, people who put
patients first, who everybody absolutely loves, but they get the boot.
Why? They haven\'t published enough papers. They haven\'t done enough
research.

Have they fallen in down in their responsibility of professionalism or
is it the academic institution and administrators?

CHAIRMAN PELLEGRINO: Thank you. Dr. Rothman?

PROF. ROTHMAN: Since there\'s so little time and I am between you and
lunch, it\'s a relief that there\'s so little time. So to both you and
Professor Dresser, Jordy Cohen is back there. He\'s going to have to
take on these issues.

All I can tell you is that it ain\'t different at 168th Street than
116th Street where I come from. Oh, yes, we really want good teachers.
And every ad hoc will, on promotion, say, \"Oh, yes. We\'re really
interested in teaching.\" I just can\'t remember the last time somebody
who taught and didn\'t publish got a promotion.

And it\'s the same at the medical schools. At the medical schools it\'s
times --- look, since I went from 116th to 168th, I was stunned. I mean,
you know, we had a first book for assistant professors, a second book
for associate professor. And then I get up to the medical schools, and
these --- well, you know what that means, and they\'ve started to change
it --- 97 articles of which he is first author on 69. You know, where
are these numbers coming from? It was kind of unbelievable.

Now there are these --- the majority I\'m talking more about. There are
these new positions of, you know, clinical educator and even Columbia
which is a rather traditional place has adopted some of them.

But I think, you know, Dr. Cohen, you\'re going to take all this on
later and deal with it.

The relief of time is to be able to avoid your question of the moral
bases for doing this. The cop-out response is to say that in both of the
instances that were raised, both capital punishment and the abortion,
the profession itself rose to the position so that the question is
really not so much directed at me. Although, do I have a problem with
it? You know, no. But it\'s interesting.

It was the profession that took on the capital-punishment issue and
responded, it thought --- we won\'t have to parse out all the \"it\" ---
and it was the docs who were furious about the gag rule rather than it
being, so to speak --- it wasn\'t cases of me urging medicine to,
although I would have, but I was irrelevant to this. The profession
defined these as intrusive and violative.

Now, I mean, I\'m sure there are some examples which I wouldn\'t be
quite so happy --- well, okay. The earlier ones that I used where the
profession stood up and said, \"We will not have government support of,
you know, healthcare for the elderly,\" I mean that sort of thing. But
in those two cases that you raised, the profession did it.

I am not a philosopher and, you know, would probably not satisfy you
even at my best as to why I thought both capital punishment and
government intrusion into the examining room are inappropriate. I\'d
probably do better on the government-intrusion side. But, you know, I
like the fact that the profession took on this stand. I mean, that spoke
to its values, not my values.

PROF. GEORGE: But do you like it because of the outcome they reached?
What if the medical profession would have said, as the medical
profession once did, \"Abortion is an evil thing. We do not want you
involved in this. We will take your license away the way we will if
you\'re involved in capital punishment\"? Is it whose ox is being gored?

PROF. ROTHMAN: That\'s when we went to the courts. You\'re right. No,
no. I\'m with you all the way. It\'s horribly complicated, horribly
complicated. And, look, this committee, you know, now we\'re really more
on your turf than on mine thankfully. I mean, my line is \"how nice,\"
and I don\'t have the test case, although I did use the Medicare.

Let me just close with one last comment because I think I haven\'t given
it --- actually two comments which I haven\'t given justice to.

One, although we spoke mostly today and I spoke mostly today about the
profession\'s obligation to itself, I equally and on other occasions
have spoken at length about public policy\'s obligation to the
profession, and that is serious and every bit as important.

The easiest example to use is payments systems. Sometimes when I talk
about this at length I can talk about we really know how to raise a
screwed-up kid. I mean, we know how to do that. You know, reward one
thing one day, punish it the next. I mean, we can really teach you how
to screw up your kid. How to raise a good kid is much more complicated.

We know how to set up a payment system that will be most subversive of
professionalism. We witnessed this in managed care. Set a system up that
rewards physicians absolutely to 70 percent of their salaries to the
degree that they don\'t send patients on to specialists. I mean, we know
how to do it badly.

The challenge: How does public policy treat the profession the way the
profession should be treated? I mean, so don\'t hear me as only charging
the profession. The issues of payment, for example, are infinitely
complicated. But how do you pay professionals in ways that promote
professionalism rather than subvert it --- that kind of exercise?

The last point which we didn\'t get into although it\'s been intimated a
little bit, and I just want to throw this out for your consideration and
others will do it, and Dr. Foster raised this a little: The
extraordinary change in the workforce.

Columbia, again, is not of the most advanced on this. But 50 percent of
the medical school class is now women. When you said, by the bye, that
there are no white men, what was the field? I mean, I didn\'t know if
you were talking about ob-gyn or peds.

DR. FOSTER: I was talking about internal medicine.

PROF. ROTHMAN: Internal medicine. Well, it\'s not quite that way at
Columbia and New York. But the predominance of women --- and that raises
another kind of fascinating issue in professionalism that I\'m just
going to drop with you as closing.

A lot of the \"good old days\" boys talk about medicine as 24/7. You\'ve
got to be ready all the time, etcetera, etcetera. And I\'ve been in
rooms where young women professionals have said, \"Don\'t you dare
define medical professionalism as requiring me not to have children, not
to pay attention to my children, not to be married, not to be able to,\"
you know. And the conflict of interest, which is not only financial,
but, you know, \"My kid\'s in a play today,\" or, you know, \"It\'s my
anniversary,\" those sorts of issues, which I think again are very, very
important, and I\'m not sure that looking back will give us all the
answers.

I guess what I was trying to do mostly today, and then I\'ll stop, is
we\'re really into some interestingly novel new areas. And although the
look back is useful and it can tell us some things, the interesting
challenges are the changes in the profession, the changes in the
society, and in the context of the practice of medicine and how does
professionalism become relevant to those new developments, whether it\'s
women, whether it\'s the kind of financial incentives that you describe,
or the other issues that we\'ve described today.

It\'s exciting, and I\'m comfortable thinking about it more
collectively. Look, a lot of people think about that doctor-patient
relationship. Less of us are thinking about the larger context of the
profession. And it\'s been exciting to do it and it\'s actually been
fun, and I thank you for making it even more interesting and
challenging.

I\'ve enjoyed this question and answer period and discussion enormously,
and my gratitude to you for having me here.

CHAIRMAN PELLEGRINO: And we thank you very, very much, Dr. Rothman. Your
contribution was spirited, informative, stimulating, provocative, and
not always right.

*(Laughter.)*

PROF. ROTHMAN: I accept all of that. Thank you.

CHAIRMAN PELLEGRINO: We will return at 2:00 o\'clock. I think we can
make that even with the overrun.

(*Whereupon, the proceedings in the foregoing matter went off the record
at 12:20 p.m. and went back on the record at 2:00 p.m.)*

CHAIRMAN PELLEGRINO: This afternoon we will continue the discussion of
professionalism, and we will begin the discussion with Dr. Jordan Cohen,
who is Professor Emeritus of the Association of American Medical
Colleges, and very much instrumental in the development of current ideas
and contemporary directions in professionalism.

Jordan, it\'s all yours.

DR. COHEN: Thank you very much, Ed, and to the Council for the
invitation. It\'s really an honor and a privilege to be able to share
some thoughts with you. I was very much informed by the discussion this
morning that David Rothman stimulated. I think your comments and your
questions were awe inspiring, I must say. So I\'m not sure I can answer
the gauntlet that David threw down at me, but I will give it my best
shot.

Anyway, how do I give my presentation? If I just do this, something good
will happen *(indicating microphone)*. Fabulous, good.

Well, I want to begin with a quote from a wise man that I once knew, who
said, \"Across history, culture, nation, ill persons are vulnerable,
dependent, nervous, fearful, and perhaps most importantly, exploitable.
They are dependent upon physicians\' technical knowledge and skill. The
physician invites trust\" --- and I would urge you to keep that word in
mind\" --- and the patient is forced to trust. Fidelity to this trust is
the moral compass that must always be the profession\'s guide.\" You
won\'t be surprised who said that.

So Dr. Pellegrino not only has inspired much of the contemporary
discussion about professionalism and the ethical and moral foundations
of medicine, but I also, in the interests of full disclosure, have to
tell you that he was my academic grandfather.

One of the medical schools he started at Stonybrook, I had the privilege
of being the dean once removed from Ed\'s tenure there. So I have had
the privilege of knowing him and admiring him for a very long time.

Well, let me hearken back to your June Council meeting, because, again,
I thank you for giving us the opportunity to review that session, and
particularly the comments of William Sullivan, who presented the
theoretical basis for the importance of professions, professional work
and professionalism.

And I took away, at least his take-home message to me was, that society
reaps essential benefits from professions as long as professionals
adhere to the core principle of professionalism, that is, placing public
interest ahead of self interest.

And then Arnold Relman, in a very impassioned recitation of his
concerns, he detailed what many of us I think are concerned about, the
contemporary threat to professionalism that is posed by commercialism
and by the investor-owned enterprises that have proliferated over the
last several years in our health care system.

His take-home message was we should purge the healthcare system of the
alien profit-oriented value system of commercialism and restore the
traditional service-oriented value system of professionalism.

Well, what David Leach and I have been asked to share with you today is
the perspective of medical education. And I\'m going to take the medical
school, the undergraduate medical education perspective, and David will
follow with the second phase of formal education, the graduate medical
education.

But from the medical school\'s perspective, and again, I have to confess
this is as much my own personal perspective as the medical school\'s
perspective --- I\'m not sure I can speak for the medical school
perspective --- but from my perspective, I think the threat that Dr.
Relman highlighted is clearly real.

At least in my professional lifetime, I don\'t think I\'ve ever seen a
period of time when there has been as much concern and assault on the
basic fundamental commitment of professionals to their ethical
foundations as is the case today.

And I often try to capture this in contrasting the models of
commercialism, or the marketplace, with the motto of medicine. The motto
of the marketplace is \"Caveat emptor,\" buyer beware. When you enter
into a commercial transaction, you have to assume that the person on the
other side of that transaction is interested in his or her purposes and
self-interest, not primarily interested in your interest and concerns.

The motto of medicine? \"Primum non nocere,\" \"First, do no harm.\" The
first obligation of the professional, the medical professional, is to
insure that that interaction is to the benefit of the patient, and
certainly not to the harm of the patient.

So that, at least to me, captures the tension between the commercialism
ethic and the professional, medical professional ethic. And it\'s
captured in a lot of the verbs, or a lot of the words that we use to
describe those interactions.

We have \"patients\" rather than \"customers.\" We have \"doctors\"
rather than \"providers.\" We have \"care\" rather than \"profit.\" So a
lot of what is in the vernacular I think captures this important
difference.

And the degree. As Dr. Relman expressed extensively and very well, there
is a real threat to the fundamental medical ethic by the commercial
enterprises that are so much in evidence in medicine today. So the
threat is real.

Trust in the medical profession does appear to be waning. In fact, there
are some studies that document, in terms of public polling, that the
public is less confident about the profession. They still express a
great deal of confidence about their individual physician, but they have
over time seemed to be less convinced that the profession as a whole is
organized and behaving in a way that is to their particular liking or
expectation.

So I do think, again, anecdotally, and again, Professor Rothman gave you
a series of recent articles and they are coming, as he said, daily, that
sort of document in the public press the concern that\'s being expressed
in that arena about the lack of professionalism among some of our
colleagues.

And clearly, I think, at least I would argue, that sustaining trust is
absolutely critical for insuring safe and effective care. And why do I
say that? Because I don\'t think that there is anything that can protect
the patients like trustworthy physicians.

We can\'t depend upon the marketplace to have a primary interest in
protecting patients\' interest. Nor do I think we can depend upon
government to establish regulations that can prevent the potential
dangers that entering the medical interaction poses.

So, no laws, no regulations, no patient bill of rights, no watchdog
federal agency, no fine print in an insurance policy, and certainly not
even the President\'s Council on Bioethics, I think, can substitute for
having a trustworthy physician who is honor-bound to act in such a way
as to be in the best interests of the patients and of the public.

Now, what is professionalism? Well, as has been discussed several times,
it\'s been bandied about, there\'s lots of different definitions. The
one that I tend to focus on, the one that I use in my own teaching, is
an articulation by a consortium of organizations, the American Board of
Internal Medicine Foundation, the American College of Physicians
Foundation, and interestingly, the European Federation of Internal
Medicine.

This was an effort to try to see whether or not in the contemporary
world of medicine one could articulate or identify a set of principles
and responsibilities for physicians that were transnational, at least
transatlantic in nature, and not just specific to the American
circumstance.

So this group was convened with the representation of our European
colleagues to see if one could come up with a statement that captured in
contemporary vernacular the fundamental principles and responsibilities
of professionals.

And the Physician Charter that you may already have had presented to you
in one form or another, but I want to briefly remind you what the
Charter called for, because I do think it answers at least some of the
issues that Dr. Kass mentioned earlier today about the difference
between a healer and a professional.

The fundamental principles that this group identified were sort of the
time-honored pre Hippocrates principle, the primacy of patient welfare.
I think that\'s the touchstone of every affirmation of professionalism
that I\'ve ever read.

A more recent, but I think, again, historically quite old view of
professionalism is based on the principle of patient autonomy, that
patients have individual rights and a sense of identity, that one cannot
violate a competent patient\'s interests or desires.

So one always has to be operating with the notion that the patient is an
autonomous human being who has his or her own set of values and
interests in that transaction.

As far as I know, there has been no previous formal statement of medical
professionalism that has as explicitly included social justice as part
of the individual physician\'s professional responsibility as a
principle of those responsibilities.

But the Charter group felt that given the modern world with all its
complexities and all of the difficulties that are involved in the
organization of medicine and the financing and delivery of healthcare,
that social justice was an important element of the commitment of
physicians to professionalism.

And it went on then to identify ten categories of professional
commitments that were called for under the three principles.

The first, professional competence. Obviously, a fundamental
requirement, and again, Dr. Kass, I think, this is the healer component
of the doctor\'s responsibility, to be competent, to have the expertise
that is advertised, and to deliver that competence and maintain that
competence through a lifetime of a career. And that is a fundamental
commitment, to maintain that competence.

And I\'m sure Dr. Leach will speak more about that, because that\'s a
very important part of the modern challenge to professionalism, is to
maintain that competence through a lifetime.

Second is to be honest with patients. Again, a fundamental
responsibility, commitment of physicians, always to be honest, to
maintain patient confidentiality, to maintain appropriate relations with
patients, not to abuse the power gradient that almost always exists
between doctor and patient, to be sure that that gradient is not
exploited at the disadvantage of patients with sexual abuse, other kinds
of inappropriate relations.

Scientific knowledge. A commitment to use scientific knowledge,
evidence-based medicine, use the best science that\'s available for the
decisions that are made. But also to continue to support the advance of
the scientific basis of medicine, continuing to explore new knowledge
and develop new ways and better ways of delivering healthcare to our
patients.

Professional responsibility. Much of what Dr. Rothman spoke about this
morning was the commitment of individual physicians, professionals, to
maintain a professional set of organizational structures that can in
fact interdigitate with society in such a way as to fulfill the
professional commitments. So individual physicians in this view should
be committed to involving themselves in professional responsibilities in
order to fulfill their obligations under the social contract.

Now, the next three are really under the rubric of social justice and
getting into the issue of civic professionalism, if you will. Improving
the quality of care---something, again, that is terribly important,
given what we now know about the errors that are rife in medical
practice and some of the difficulties of maintaining a patient\'s safety
in our systems, taking advantage of the knowledge that we now know from
other walks of life about the way to improve, continuously improve the
quality of care.

To improve access to care. Again, individual physicians have a limited
ability in their own individual practices to improve access to care,
although that\'s always been a traditional commitment. The AMA has
called for physicians always to open up their practices to indigent
patients. But clearly it\'s a commitment that needs to go beyond the
individual physician.

And a just distribution of resources. Similarly, there\'s only so much
individual physicians can do in their dyadic relationship with patients
to insure the just distribution of resources. But a commitment to
involve themselves in a civic professionalism to accomplish this.

And finally, and I would say most importantly, clearly from the
standpoint of our discussion today, is to maintain trust by managing
conflicts of interest. Again, the conflicts of interest that Dr. Relman
spoke of and Dr. Rothman spoke of this morning I think are inevitable in
our complex circumstance. And our obligation as medical professionals
and to fulfill the commitment of professionalism is to manage those
conflicts of interest. Eradicate them when possible, but recognizing
that it\'s not ever possible to completely eradicate conflicts of
interest.

We all have conflicts of interest in everything we do, not just in our
professional work. And so it\'s not a question of eliminating conflicts
of interest, but it\'s recognizing them, managing them, insuring that
they do not overarch or trump our commitments as professionals when
we\'re in that kind of relationship.

Well, that\'s sort of the framework in which medical educators now are
trying to fulfill their obligation. And I just wanted to say a few words
about that.

So, sustaining trust is what fundamentally professionalism is all about.
It\'s maintaining this understanding between individual patients and
their doctors and between the public at large and the profession as a
whole that we can be trusted with this responsibility that we have to
work in the public interest.

Professionalism in medicine is centered on the primacy of patient
interest. And we had an interesting discussion this morning about what
patient interest is. And I would concede that that is a very vague term,
in terms of the kinds of interests that we\'re talking about.

But in the context of this discussion, I think we\'re talking about what
is in the best interests of insuring and maintaining that a patient\'s
health is the interest that that patient has when entering this
relationship.

What a professional does is choose voluntarily, and I think that\'s an
important part of this notion, that this is an honor-bound commitment, a
voluntary commitment, to place the patient\'s interest ahead of one\'s
self interest.

Clearly, we all have self interest. There is no denying that, or we
should not shy away from that recognition. But it\'s a question of how
you balance one\'s own interest against the obligation of a professional
to voluntarily concede that interest in favor of the patient\'s
interest.

Rampant commercialism in today\'s health care system does in fact, I
think, offer unprecedented temptations to physicians to yield to self
interest. And here I want to make the point that I think is obvious to
all of you, namely, that we\'ve never, in the history that I know of in
medicine, been free of temptation to violate this ethic of primacy of
patient interest.

There\'s always opportunity. There always have been opportunities for
physicians to express their self interest, in how often they see a
patient, what tests to order, what diagnoses to make---all kinds of ways
in which the relationship between a doctor and a patient can be
exploited for self interest. And that\'s never been absent from medicine
in time out of mind.

What is, I think, changed in the modern era is the magnitude---the
extent of those opportunities and the magnitude of those opportunities
for temptation. So Relman\'s answer to this dilemma, or this reality of
the temptations that are so much in evidence, is to reduce those
temptations. And I don\'t think one should discount the absolute
importance of that effort.

Whatever we can do to restore a better balance between the temptations
that are always there and what physicians have to confront in fulfilling
their professional obligations is clear. But clearly, to reduce those
temptations to the extent possible is a very important part of the
effort to try to sustain professionalism under the modern circumstances.

And I would say as a quick and dirty summary of what medical
education\'s answer to this dilemma is, is that we are responsible as
educators to bolster the resolve of future physicians so that they can
withstand the inevitable temptations that are there. So we don\'t see
the job of education as addressing these larger societal issues,
although I will come back to that at the end of my talk.

But rather, our focus is recognizing that those temptations are always
going to be there in some form or another, no matter how successful we
are in reducing them, but that we want to be sure that our trainees, our
students and our trainees, are sufficiently fortified with their
commitment to this fundamental ethic so that they can withstand these
temptations and maintain their resolve to keep the patient\'s interest
uppermost.

So, how do medical schools go about doing that? And again, I was very
taken with the article in your agenda book by Coulehan, who talked a lot
about the current ability and mechanisms that are at play in medical
schools to try to bolster professionalism. And I think he\'s right, that
we haven\'t yet done an adequate job.

We have a lot more that we can do and should be doing in order to make
this more of a reality. And I think some of his suggestions are
extremely well put. Another Stonybrook graduate, by the way, just to
give proper acknowledgment to Dr. Pellegrino\'s legacy.

In any event, the first thing, and perhaps the most important thing that
medical educators at the medical school level can do is to insure that
the students who are accepted into medical school, as best we can, have
the requisite character traits in order to provide the substrate to
develop these professional commitments.

And this is, I think, a task that medical schools have understood for a
long time. We recognize that, given the fact that --- I don\'t know what
the figure is currently --- but something like 97 percent of medical
students who are admitted to medical school receive the M.D. degree.
Many of those who don\'t graduate choose to leave medical school, for
reasons that they just made the wrong choice.

So it\'s very difficult to flunk out of medical school. It takes a lot
of effort to flunk out of medical school. So the upshot of that is that
the medical school admissions committee is really the entry point to the
profession. They are the gatekeepers, if you will. That\'s where people
get from laity into the priesthood, is through the door of the medical
school admissions process.

So there\'s a tremendous amount of importance that\'s laid at the
doorstep of the admissions office in order to develop whatever
techniques they can to insure that those students who do gain entrance
to medical school have the requisite character traits.

And as I\'m sure you know, there are now over twice as many students
applying to medical school as there are places in our current medical
school classes. So this is a daunting task, to try to select among those
very talented people, those that have not only the intellectual and
academic backgrounds that are predictive of success, but they also have
the evidence of these character traits.

Now, how do you measure that? What sort of tools are used? We all
recognize that we have very imprecise ways of identifying students who
are truly committed to these professional norms and the moral basis of
the profession.

But I think by and large, admissions committees do a very good job.
There are very few students who turn out to be psychopathic or really
fall far short of the expectations of the profession, not to say that
there isn\'t a great deal more that we could and should be doing in
order to sharpen that requirement, and sharpen that decision-making so
that we can even more certain that these students that we admit do in
fact have these requisite traits.

My own anecdotal observation --- and I\'d be interested in you all\'s
view of this yourself --- I think we are admitting an exceptionally
talented, idealistic, committed group of students. And I would credit
some of that to the fact that we now have as many women as we have men
in the entering class. I think the women have done a lot to improve the
atmosphere of the profession and have, I think, contributed to this
sense of service, sense of obligation to others.

In any event, whether that is a reality or not, the fact is --- or at
least the impression I have, the strong impression I have, is that the
students that are now coming into the profession are endowed with a very
rich resource of personal characteristics that I think ensure that if we
can keep that alive --- and that\'s the big challenge---that we will
have a future cadre of physicians that will in fact be resilient to the
threats and the temptations that are out there.

Well, secondly, it\'s clear that at least one of the things medical
schools need to do is to organize their formal curriculum so they can
address not only the rationale for professionalism, but also be sure
that our students understand what the barriers and the threats to
professionalism are as they go through their professional lives.

Again, I agree with Dr. Foster that the formal curriculum is important,
but clearly not the be all and end-all. It\'s nowhere near as important
as the role modeling and the kind of experience that students have going
through particularly their clinical education.

But nevertheless, I would like to underscore the fact that there is a
need for some formalism, some didactic experiences, some knowledge base
and cognitive understanding of what professionalism is about, its
historical underpinnings, and, again, particularly the threats that our
students and residents will eventually encounter during their
professional life, to maintaining a commitment to those fundamental
responsibilities.

And here\'s the issue of the informal curriculum, or the hidden
curriculum, as it\'s been called. And I don\'t think there\'s any
question about the fact that many of our learning environments,
particularly in the clinical settings, are not emblematic of the kind of
professionalism that we\'d like to see communicated to our students.

There is also no question about the fact that students take away much
more strongly the lessons from what they see rather than from what we
say. And we need to recognize that our behavior, our interactions with
each other as professionals, our interactions with our patients, the way
the institutions operate in terms of their commitment to institutional
ethics---all of those things contribute to an environment that presently
is not nearly as conducive to bolstering this commitment to
professionalism as it needs to be.

We need to recognize that we have crucibles of cynicism, as I\'ve called
them, that we have many learning environments in which our students are
not exposed and witness the kind of level, the standard of care,
standard of interaction, standard of relationships that we would like to
see. We need to convert those into cradles of professionalism,
recognizing that that is where professional identity is truly
established in this educational context.

And finally, I think we need to be much more objective, much more
precise about what we expect physicians, future physicians, to exhibit
before they graduate. We need to give them a prospective understanding,
not only of the knowledge and the technical skills that they need to
demonstrate, but also the attitudinal and behavioral attributes that
define professionalism.

And we need to have much better ways of evaluating the achievement of
those professional objectives, just as we evaluate the achievement of a
certain degree of knowledge and technical skill. We need to be willing
and able and strong in our evaluations to sanction bad behavior, to not
pass on from one class to the next students who we know have fallen
short of this aspect of their professional responsibilities as well as
their academic performance.

So sanctioning bad behavior is part of the responsibility of the
institution. As important in fact, I think probably more importantly, to
celebrate exemplars of professionalism, to have ways in which we can
identify and hold up as exemplars the kinds of individuals and their
individual performance that does give visibility to these values that
we\'re trying to inculcate.

So there are many obstacles in medical schools, and I\'ve identified
some of these in passing. But just let me repeat that one of the issues
is cynicism among faculty role models.

We have faculty that are very stressed under the present time, by and
large, with lots of responsibilities, lots of expectations that take
their attention and their time and their commitment away from their
fundamental obligation as faculty, namely, to teach and to pass on to
the next generation these values that we\'re talking about.

And to the degree that our faculty have been frustrated in their
attempts to maintain their professional identities, that\'s very easily
communicated to the next generation.

So we need to understand that faculty are a key element here, and we
need to help them maintain their commitment to professionalism, to honor
that commitment, and to insure that what they are responsible for
achieving in their multiple roles does not undercut and undervalue their
function as role models for future physicians. It\'s a huge undertaking.

Again, a lot of what is going on, as I\'ll mention in a moment, is far
beyond what the profession and what the school can really get its arms
around, because so much of this is embedded in the system of healthcare
that we are involved with that we have very little opportunity to
directly influence.

But nevertheless, I think we have to recognize this as an issue and
redouble our efforts to try to insure that faculty are not converted to
cynics in the process.

Conflicts of interest in clinical research is another barrier. We\'ve
had, I think, a very interesting period in our country over the last
several decades, where we\'ve recognized the really very important
public purpose that\'s served by academic institutions involving
themselves with commercial entities and translating basic science
discoveries into useful services and products for the public.

And this interaction, again, serves a very important public purpose. But
it has a very important caveat, and that is the degree to which
conflicts of interest, financial conflicts of interest in particular,
can become embedded in those relationships to the degree that at least
there\'s the perception, and I think clear evidence of some actual
threats, to not only the objectivity of the research results, but more
importantly, the safety of patients in clinical research when there is
conflict of interest that overrides the fundamental commitment to
maintaining patient safety in these clinical research enterprises.

So the fact that those conflicts of interest are evident in our
institutions and in some instances not well managed I think again
contributes to an atmosphere where professionalism is difficult to
sustain, for students.

And as Dr. Rothman mentioned this morning, in detail, the intrusion of
industry into the educational process in so many different ways, in
terms of direct support for education, obviously, mostly continuing
education, but increasingly in undergraduate and graduate medical
education as well, there are attempts by industry, and some successful
ones in fact, to involve themselves in a direct way, at least, again,
with the potential of introducing bias into the educational process.

The gifting, the detailing, the faculty involvement in speaker\'s
bureaus, in ghost-written articles and that whole gamut of issues that

Dr. Rothman detailed I think again poses a clear obstacle to maintaining
a focus on professionalism when the institution and those involved,
particularly in leadership in the institutions, are not adherent to
these fundamental commitments, it does make it difficult for us to
sustain the importance of professionalism among our students and
residents.

And finally, I would mention the debt burden of graduates. I think
somebody mentioned this morning that a graduate that they had talked to
had a \$300,000 debt. That\'s a little bit extreme, but not greatly
extreme.

The average indebtedness now of students who are graduating from medical
school --- and over 80 percent of students who graduate, by the way,
have educational debt --- and among that group, the average now is well
in excess of \$100,000. Many students have \$150,000, \$200,000 of debt.

The degree to which that challenges their fundamental commitment to
service is, I think, speculative. We don\'t have an awful lot of hard
evidence about the relationship between debt and, for example, specialty
choice. But I think it is reasonable, and a lot of anecdotal evidence,
that this in fact does influence physicians\' choice --- or students\'
choice of career.

Certainly, once they are involved in having to repay that debt, it does
put a higher value on remunerative activities that they may engage in.
And I think clearly the implicit message that we send to students by
burdening them with this debt is not a salutary one from the standpoint
of nurturing the future generation of physicians in a compassionate and
understanding way. So I think this is an issue that is worth some
discussion.

So, let me conclude by saying that medical schools clearly recognize the
urgency of strengthening students\' resolve to maintaining this primacy
of the patient\'s interest by emphasizing professionalism, much more ---
there\'s just much more discussion of these topics in medical schools
now than was the case even just a few years ago, stimulated again by a
lot of the things that you\'ve already heard about.

And I think the fact that there\'s now a recognition of the importance
of this topic, it\'s being talked about, it\'s being debated, I think is
obviously a very, very positive sign.

There have been clear, significant curricular innovations that are
trying to address what many of us feel has been a deficiency in the
educational activities in terms of trying to introduce not only a
didactic, but also trying to address some of these issues in the hidden
curriculum.

Stronger policies governing conflicts of interest --- Dr. Rothman,
again, mentioned several schools that have adopted very strong policies,
managing conflicts of interest within their institutions, both at the
level of clinical research as well as in the educational involvement.

We have, I think, a much more explicit reinforcement of the humanistic
values of caring, compassion, altruism, empathy, that are character
traits that we want to support.

I\'m involved with the Arnold P. Gold Foundation for Humanism in
Medicine, which is dedicated to trying to support the professional
development of the humanistic qualities in the medical education arena.

The White Coat Ceremony that some of you may know about is a signature
program of that foundation, again, at the beginning of medical school,
trying to underscore the transition that is occurring from laity, if you
will, into the profession, to ratify the importance of that transition,
and the meaning that that has in terms of their future commitments.

We have, I think, to recognize that whatever success we may have in
medical schools in terms of reinforcing these commitments that are
largely there in the students that we\'ve admitted, as I mentioned
before, does depend upon the ability of graduate medical education and
beyond to continue to develop those professional identities, and to
bolster that commitment to professionalism throughout the subsequent
phases.

I think we have the easiest job in undergraduate medical education. I
think the residency, as Dr. Leach will document, I\'m sure, is a much
more difficult issue. That\'s where much of the cynicism, much of the
unprofessional attributes that we worry about, I think, are in fact in
evidence. So we need to recognize that we can only have a certain amount
of success at the undergraduate level.

But even more important, I think success in maintaining and bolstering
this commitment to professionalism depends absolutely and exclusively on
improving the environment of medical practice, because that\'s the
fundamental problem, again, that Dr. Relman emphasized and I think we
have to come back to --- that much of what hinders professionalism is
clearly beyond the control of physicians or of the medical profession as
a collective.

Again, I mentioned the Physician Charter. The Physician Charter has been
endorsed by over a hundred medical organizations throughout the world.
But a very strong feedback, a criticism of the Charter, is that it calls
on physicians to do things that are beyond the physician\'s control.

Many of the things, as I\'ll mention in a moment, that the Charter
expects physicians to fulfill as responsibilities are very difficult if
not impossible to do given the circumstances of medical practice,
certainly in this country. It\'s not true only here, but in the United
States the system of medical care is antithetical in many respects, as
I\'ll mention in a minute, to what needs to be done.

So if you accept the assertion that I mentioned at the beginning, and
again, that Professor Sullivan emphasized in his remarks in June, if you
believe that the public has a real stake in maintaining medical
professionalism because of its fundamental safeguard to patients and the
public, far beyond what can be accomplished by the market or by
government regulation or any other mechanism, if professionalism and the
voluntary commitment of physicians to this ethical code is in fact of
public value, then it seems to me that we must have a joint effort
between the profession and the broader public to address these
system-wide barriers to professionalism that the profession itself
cannot alone manage.

And just to underscore what those might be, how are we going to manage
conflicts of interest with a payment system misaligned, as it currently
is---again, Dr. Rothman mentioned this this morning --- that the current
way in which we compensate or pay physicians for their services is in
many respects antithetical to maintaining the primacy of patients\'
interests.

We need to address the inequities in the payment system and the
mechanisms in that payment system and align them better with what we
really want physicians to do in the final analysis.

Maintaining professional competence provides adequate support for the
education and training of physicians. And burdening physicians with this
much debt when they leave medical school is something that I think needs
to be addressed.

And other supports of the medical education enterprise to ensure, for
example, that faculty has sufficient time to devote to the professional
development of trainees and students is critically important, and given
the current circumstances, very difficult to accomplish. So we need a
recognition in the broader public that that is an issue.

Maintaining scientific knowledge, obviously, giving adequate support for
medical and health services research has always been acknowledged to be
a public responsibility. But I think we have to continue to advocate on
behalf of medical research so that our public policymakers and lawmakers
understand the importance of that issue.

Maintaining honest with patients is very difficult under the present
circumstances of our liability system, where physicians are always
threatened with lawsuits when they make what is perceived to be an
error, or when an error occurs and when a misadventure occurs.

Maintaining a liability system that fosters frank discussion of those
errors is the only way we are ever going to get to the point where we
can identify the errors and improve the systems. Most of the errors, as
you know, are related to system level problems, not individual
malfeasance.

And unless we can frankly discuss those errors in an atmosphere that is
free of the threat of personal professional liability, it\'s going to be
very hard to get a handle on that issue.

So we\'ve got to construct a liability system that fairly compensates
individuals when they are injured by the system, which will inevitably
be the case, but which doesn\'t at the same time squelch the ability to
make improvements in the system.

We\'ve got to improve access to care. Obviously, individual physicians
in the profession can only do so much in providing adequate medical care
to individuals who lack financial wherewithal, either because of their
own personal resources or because they lack insurance for a basic set of
preventative and medical care services. That\'s a clear example of where
we need to have a partner with the broader public to achieve.

And finally, improving the quality of care. We\'ve got to establish
standards of inoperability for the electronic health record. We\'ve got
to have a regime of privacy laws that ensures that we can have access to
the relevant patient level data so that we can in fact make improvements
in the system.

All of these things, again, are fundamental commitments of the
professional, the individual physician, that can only be achieved, I
think, in partnership with the broader public.

So, with that I will end my remarks, and hope I haven\'t taken too much
time. Thank you, Ed.

CHAIRMAN PELLEGRINO: Thank you very much, for a very complete and very,
very incisive presentation on the whole range of issues involved in
professional education.

With the indulgence of the Council, I\'ve asked, and I will ask, Dr.
David Leach to continue the discussion, and then the Council itself can
put questions to both of the speakers simultaneously.

Dr. Leach is the Executive Director of the Accreditation Council on
Graduate Medical Education, that area of medical education where really
the habits and attitudes of physicians are most frequently and most
strongly formed. Dr. Leach.

PRESENTATION BY DAVID LEACH, M.D.

DR. LEACH: Let me begin by thanking the Council and its distinguished
members for the opportunity to share my thoughts and observations about
medical professionalism, especially as it applies to the formation of
resident physicians.

Medicine, unlike most professions, requires a period of formal
supervised training after graduation. These educational programs, called
residencies, are accredited by my organization, the Accreditation
Council for Graduate Medical Education, the ACGME. There are about 8,600
residency programs in the country, programs that in aggregate house
about 106,000 residents in 122 different specialties and subspecialties.

Residency is an intense experience. There is probably no steeper
learning curve in physician formation. The differences in knowledge and
skill between a first-year and chief resident is profound. The
resident\'s journey is one in which they learn both the practical skills
of medicine, the clinical wisdom, but also they learn about themselves.

They are seeking to become authentic physicians. It\'s a journey that is
surrounded by external drama, but which actually proceeds from the
inside out. It is a journey that calls on their intellect, but also on
their will and their imagination.

Residents learn to discern and to tell the truth and to make good
clinical judgments in very complex clinical situations. Because of the
intensity and importance of this most formative phase in physician
development, and because the habits of a lifetime are developed during
this period, we pay attention not only to the resident\'s progress, but
also to the context in which residency occurs.

The learning environment is crucial and is monitored by ACGME\'s
Institutional Review Committee. Residents in the residency programs
offer a particular view of the issue you are studying ---
professionalism and whether there is a crisis in the medical profession.

One of my mentors, Parker Palmer, a sociologist in Madison, Wisconsin,
has said, \"Hope is not the same as optimism. An optimist ignores the
facts in order to come to a comforting conclusion. But a hopeful person
faces the facts without blinking, and then looks behind them for
potentials that have yet to emerge, knowing that the human experiment
would never have advanced if it were not for the possibilities, however
slim, that lie behind the facts.\"

Using Palmer\'s definition, I can say that I am cautiously hopeful, but
definitely concerned. In May of 2002, he facilitated a retreat for
residency program directors who had received the ACGME\'s Parker Palmer
Courage to Teach Award.

During the retreat, a case was presented, a case in which a liver
transplant donor had died while in intensive care. He died despite the
fact that the surgery had gone smoothly, and despite the fact that his
wife, who was with him throughout the entire postsurgical period
insisted repeatedly and to no avail that her husband was going downhill
fast.

Three months later, the state health commissioner issued an incident
report saying the hospital allowed the patient to undergo a major
high-risk procedure and then left his postoperative care in the hands of
an overburdened mostly junior staff without appropriate supervision.

On the day the donor died, a first-year surgical resident, having been a
resident for three months, and having been in the transplant unit only
12 days, had been left alone to care for 34 patients. She could not and
did not monitor every patient with the care and precision required.

I present this case as an example, perhaps an extreme example, of
abandonment --- not only of the patient but of a very junior resident. I
also present it because of the response it evoked from a set of doctors
analyzing it.

The doctors at the Courage to Teach retreat discussed the case in small
groups, and almost universally came to the conclusion that system issues
were to blame. The analysis was impersonal and abstract. The culpable
parties were the hospital leadership, the clinical department chair, the
system of supervision, inexperience in staffing.

During the debriefing, Parker Palmer asked the question that brought the
group into deep silence, \"Who is the moral agent of this story?\" We
were not used to thinking in terms of moral agency. The group agonized
over the question, and the fact that by habit we had avoided asking the
question.

Parker then inquired, \"What if residents were expected to be the moral
agents of the institutions in which they work and learn?\" He suggested
that young learners not yet acculturated by prevailing institutional
mores offered a more pure look at the moral issues in health care than
those of us who by experience and habit had developed a ready list of
explanations to cope with such failings.

I realize that one topic of interest to this Council is the effect of
various external forces on professionalism. For example, investor-owned
interests in health care money and its influence, and even its influence
on educational programs.

I share Dr. Relman\'s concerns. He has spoken and written eloquently,
and I cannot add to his comments. Commercial support has some, but so
far limited, direct influence on residency education.

We do have a position paper and guidelines on the topic, but I think it
is fair to say that compared to commercialism\'s influence on the larger
healthcare system, its role and influence in graduate education is quite
limited.

Instead, I speak today more to the internal influences on the developing
professional. I think of medical professionalism as more potato than
lettuce. Lettuce rots from the outside in; a potato from the inside out.
I put commercial support of education into the lettuce category. It
should not happen. Fixing it might involve removing some of the outer
leaves of the lettuce that appear brown and slimy. For me and for many
who take residency education seriously, the question of professionalism
is deeper. How do we preserve and nurture authentic human moral reflexes
in our young learners? How do we foster authentic professionalism and
moral development in young people, when the context in which young
people are being formed is itself challenged morally?

ACGME has identified professionalism as one of six general competencies
used in the accreditation of residency programs. ACGME requirements
about professionalism include this language: \"Residents must
demonstrate a commitment to carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to a diverse patient
population.

\"Residents are expected to demonstrate respect, compassion and
integrity, a responsiveness to the needs of patients and society that
supersedes self-interest; accountability to patients, society and the
profession; and a commitment to excellence and ongoing professional
development.

\"Residents are expected to demonstrate a commitment to ethical
principles pertaining to provision or withholding of clinical care,
confidentiality of patient information, informed consent and business
practices.

\"To demonstrate sensitivity and responsiveness to patients\' culture,
age, gender and disabilities.\"

As this definition makes clear, medical professionalism depends heavily
on the quality of the physician\'s inner life. Transcendence of
self-interest is not a technique; it is a way of being. The resident, in
addition to learning the science and art of medicine must also learn a
new way of being in the world in order to become a fully developed
professional.

Their journey is an inner journey. We have a heavy obligation to help
them. Though the journey is deeply personal and inner, it is heavily
influenced by context, both institutional and societal context influence
the development of professionalism.

Is it possible to model and teach professionalism in institutions that
do not demonstrate professional values? Is it possible to teach and
model professionalism in a society that does not demonstrate social
justice, a society that accepts limited access to health care for the
uninsured, and that tolerates demonstrably worse healthcare outcomes for
the poor?

No, the current context in which healthcare and resident formation occur
does not make the task of fostering medical professionalism easy.
Relentless pressures of time and economics, fragmentation of care and
the relationships supporting care, increasing external regulation,
exciting but disruptive new knowledge and technologies, and above all,
the broken systems of healthcare dominate conversations and characterize
the external environmental context.

The internal context of the system of care is also daunting. We lie
regularly. Justifiable lack of trust pervades the system. Beth McGlynn
estimates that only 54 percent of the time do patients receive care that
is known to be best --- a number that falls to 2 to 3 percent of the
time when evidence-based guidelines are bundled.

Hospital websites proudly announce that the hospitals they promote
provide the best care with the best doctors, the best technology, et
cetera. Some are so detached from acknowledging human suffering that
they make it seem as though a hospital might be a fun place to visit.

As a profession, we have tolerated that messaging, forgetting Hannah
Arendt\'s adage that every time we make a promise, we should plan for
the forgiveness we will need when the promise is broken. The hospital
bill offers another example of a breach in professionalism. It is
frequently not interpretable, even by the hospital\'s own administrative
staff, let alone patients and their families.

Paul O\'Neill has said that he knows of no other industry that regularly
accepts a 38 percent reimbursement on amounts billed, a percentage that
he states is the national average.

We all know how the number is derived. Hospitals actively negotiate with
several insurers in ways designed to cover costs. Inflated bills and
discounted deals result. This system, while cumbersome, works from the
hospital\'s perspective as long as aggregate reimbursements cover
expenses and some margin.

The system works fine, that is, until a patient shows up with no
insurance. With no one to negotiate for a discounted rate, then the
undiscounted fees are billed to those least able to pay. The hospital
bill is about as far away from respect, compassion, and integrity, a
responsiveness to the needs of patients, as one can get.

It\'s hard to foster professionalism when incongruities between espoused
and evident behaviors are so apparent. I call this the \"Abraham
Verghesse problem.\" At a spectacular forum sponsored by the American
Board of Internal Medicine in the summer of 2005, the audience was, with
some justifiable pride, celebrating the accomplishments of the Physician
Charter on Medical Professionalism.

This very well-written document endorsed by many clarifies principles
and commitments in a very important way. And yet, in the midst of the
celebratory speeches, Abraham Verghesse stood up and said that his
medical students shrugged that the principles espoused in the Charter
were self-evident, it was why they went into medicine. Why were so many
making such a fuss about it?

Dr. Verghesse then said, \"Perhaps we pay so much attention to the words
because there is no other evidence that the phenomenon exists.\"
Everyone became silent. In spite of these examples, I remain cautiously
hopeful, using Palmer\'s definition. Why?

There is a deep hunger for a return to classic professional values. Many
good people are seeking clarity about how to best do that in the modern
world. And because, as Parker says, \"in looking for the potentials that
have yet to emerge, and at the possibilities hidden behind the facts,\"
we can find allies that help us move this particular human enterprise
forward.

Dee Hock has said, \"Substance is enduring; form is ephemeral. Preserve
substance; modify form; know the difference.\" The task before us is to
be faithful stewards of the moral foundations of medical
professionalism, while adapting to the new and emerging forms of medical
practice.

If in fact medical professionalism is like a potato and not just
lettuce, our response to the new forms of medical practice will either
reveal deeper lesions of professional values or not. How can we best
proceed?

I think it\'s best to work with rather than against human nature.
Residents, their teachers and all humans come equipped with three
faculties that are naturally aligned with the goals of professionalism:
the intellect, the will, and the imagination.

The object of the intellect is truth; that of the will, goodness; and
that of the imagination, beauty. The job of a good doctor boils down to
discerning and telling the truth, putting what is good for the patient
before what is good for the doctor, and making clinical judgments that
harmonize---harmonize in ways that are creative and sometimes beautiful
--- the particular needs of a patient with the generalizable scientific
evidence at hand.

This construct invites a new frame, or rather a very old frame, for
organizing experiences. How good a job did I do in discerning and
telling the truth, in putting the patient\'s interest first, in
accommodating the particular realities of the patient\'s situation in my
clinical judgments?

While we have a long way to go, some hospital websites are beginning to
tell the truth about their clinical outcomes. If you go to the Dartmouth
Hitchcock website, you will find a list of several clinical procedures
and diseases and Dartmouth\'s performance for each displayed in three
columns: Dartmouth\'s performance, national average, and national best
performance.

While still unavailable for most hospitals, Dartmouth is not alone in
its transparency. Others are beginning to follow. If you look at the
Cystic Fibrosis Foundation website, you can get comparative outcome data
for each of the major cystic fibrosis treatment centers in the country.
While not yet true for other diseases, that inevitably will be. As a
profession, we are beginning to tell the truth.

We are also beginning to tell the truth about medical error. Many
hospitals now have formal programs in which patients are told exactly
what happened, are given an apology, and some evidence that the hospital
staff are working to reduce the probability of that error occurring
again.

To do this work we must acknowledge that we the teachers of medicine
must attend to our own inner landscape. Teachers who take resident
formation seriously find that both resident and teacher are changed. The
journey to authenticity is not being taken by the resident and faculty
alone. The profession of medicine is on the same journey.

For that matter, our American society is on a journey to authenticity as
well. To the extent that our profession discerns and tells the truth
about healthcare, to the extent that it puts what is good for the
patient and the public before what is good for the doctor, and to the
extent that it is creative and generative, it is an authentic
profession.

Authenticity in this sense is a verb, not a noun. It is not a state of
rest. It requires constant vigilance. Residencies and the institutions
that house them should be built on the bedrock of the intellect, the
will and the imagination, and offer experiences that strengthen and test
these capacities.

We must debunk the myth that our institutions are external to ourselves.
We tend to accuse others of our own sins. We tend to blame the nebulous
\"they\" for violations of standards that we alone and together must
defend.

This from Parker Palmer: \"Professionals who by any standard are among
the most powerful people on the planet have the bad habit of telling
victim stories to excuse behavior. \'The devil made me do it.\' The
extent to which institutions control our lives depends on our own inner
calculus about what we value most.

\"These institutions are neither external to us nor constraining,
neither separate from us nor alien. In fact, institutions are us. The
shadows that institutions cast over our ethical lives are the exterior
manifestations of our own inner shadows, individual and collective.

\"If institutions are rigid, it is because we fear change. If
institutions are heedless of human need, it is because something in us
is heedless as well.\"

In our journey to authenticity as a profession, we must call
institutions to account as we call ourselves to account. We may pay a
price; we may be marginalized, demoted or even dismissed. But the price
we pay for continuing to pretend that we are helpless victims, the price
we pay for living professional lives in conflict with our deepest
values, is greater.

We must resist unprofessional institutional behavior not because we hate
our institutions, but because we love them too much to allow them to
fall to their most degraded state. Perhaps we should take seriously
Palmer\'s suggestion that we create a system in which residents and
other early learners could function as moral agents.

Like the canary in the coal mine, they could detect and warn others when
institutional conditions and relationships are toxic to professional
values. They could keep us honest about how we are dealing with the
sick.

This approach would require that we both listen to and validate
residents\' feelings, and that we train them to use the human heart as a
source of information. This, of course, is problematic. Embedded in the
higher education process is a systematic discounting of the subjective.
It is thought to be a source of bias and unreliability.

And yet, good physicians do more than simply pay attention to objective
details. Compassion, empathy, and deep respect are all dependent on
truths revealed by the human heart. Perhaps the heart, like the mind,
can be taught to discern truths. Perhaps when the heart is uneasy, we
should listen more carefully and mind the information it is giving us.
Perhaps a disciplined approach could enable moral agency to develop.

Lacking a disciplined approach, we too frequently socialize residents to
cope with, rather than to master, the systems in which they work and
learn. They live in the cracks of a broken system; they are the glue
that hold it together. They get things done.

Yet, as many have said, they are renters and not owners. They can
identify system issues but don\'t feel empowered to fix them. Coping
with systems in which patient safety depends on individual vigilance
rather than design is wearing and dangerous, and we will fail every
hundred or thousand times, well below what we know is achievable in
other sectors of our society today.

It also inhibits the formation of true professionalism. The solution
requires attention to group as well as individual formation. We have
assumed that professionalism is an attribute of individuals alone. It is
not. It also marks communities.

The assumption that the doctor-patient relationship is a one-to-one
relationship is flawed. In fact, it is more like a twenty-to-one
relationship, with several different types of doctors, nurses, and other
healthcare professionals interacting with the patient and each other in
ways that are variable and frequently disorganized. Needed is clarity
about the roles, authorities, and functions of the various members of
the healthcare team.

Cultivating communities to discern and tell the truth to each other, to
enable and facilitate altruism, to make good promises and to seek
forgiveness, and to harmoniously integrate true hospitality into care
plans depends on paying attention to small group as well as individual
formation. It will help us respond to society\'s call for respect.

Lastly, we must not stand passively by when our country violates
fundamental principles of social justice. Every resident physician
encounters the poor. Many academic health centers include care of the
poor as part of their mission, and are frequently the backbone of such
care for their communities.

Yet widespread disparity exists across the larger society even within
academic centers. The profession has been ineffective at best and silent
at worst about healthcare disparity. We would be well served to have a
bias toward rather than against the poor. The larger society judges us
over time by our response to their needs.

We live in a society in which truth is viewed as nothing more than a
social construct. Spin doctors rather than real doctors prevail. They
can construct a view of social justice that will serve their master.

Medicine in its very nature functions under a different set of
assumptions. Rather than a postmodern socially constructed view of
truth, doctors deal with things like gallstones and brain tumors.
Medicine accepts that there is a truth and that it can be known,
although sometimes with great difficulty. A gallstone is not a social
construct.

A doctor may or may not be able to detect it, but ultimately, truth
trumps opinion. If we by habit discern and tell the truth, we can offer
the larger society an approach to truth that conforms with reality,
rather than mere social constructs that attempt to create reality.

Good doctors are humble. Even the arrogant ones encounter failure.
Postmodernists lack that corrective and can become quite proud, marked
by hubris and convinced that they are right. Flannery O\'Connor has
said, \"In the absence of the absolute, the relative becomes absolute.\"
This is the source of all fundamentalism, religious, political or other.

We cannot accept socially constructed views of social justice. This is
not an issue of conservative or liberal. It is deeper than that. We are
called upon to provide health care for all of our citizens. It is their
due. In a society with resources and know-how, failure to care for the
sick is a breach of professionalism.

Further, we must respond to the needs of all of our citizens in ways
that offer an exemplar for our young learners. They, too, will judge our
words and actions and grade us on professionalism. When idealistic young
people are told to adjust their values downward in order to accommodate
our accommodation, we have a problem.

If we get this right, the crisis in professionalism will fade, and we
will have achieved the next step on our own journey to authenticity. We
can deal with external threats once our internal values are sound and
our courage is found. Thank you very much.

CHAIRMAN PELLEGRINO: Thank you very much, Dr. Leach. Dr. Carson has
consented to open up the discussion.

DR. CARSON: I want to thank both of you gentlemen for your discussion
and for the very long-term contributions you\'ve made to the training of
physicians in this country. Now, this is a very, very in depth type of
discussion that needs to be had about this. I don\'t know that it can be
actually done in the amount of time that we have, because it really is a
problem.

I don\'t know if it\'s crisis or if it\'s just a problem, but it
certainly does need to be addressed. Our whole concept of how do we make
patients\' welfare the most important agenda item --- I think that\'s
perhaps the most important part of professionalism.

And I\'m going to ask a series of questions in response to what\'s been
said and what\'s been written here, just to get us started. The whole
concept of can we actually select out people who are prone to act in a
professional way, or can we take people who perhaps aren\'t prone to
acting that way and train them to act in that way?

That\'s a very profound question. Which one of those is true? Are they
both true? Perhaps not. How good are we at determining who is going to
be a good physician?

I can remember in my own case, when I was a first-year medical student,
after the first six weeks having a comprehensive exam and not doing very
well on it, and being sent to see my counselor, who looked at my record
and said, \"You seem like a very intelligent young man. I\'ll bet there
are a lot of things you could do outside of medicine.\"

And he encouraged me to drop out of medical school. He said I wasn\'t
cut out to be a doctor, and I\'d only invested six weeks, so why waste
everybody\'s time, just drop out. Well, obviously I didn\'t listen to
him. I must say I was looking for him when I went back to my medical
school as the commencement speaker, because I was going to tell him he
wasn\'t cut out to be a counselor.

But, you know, in so many cases we actually do think that we know, and
it may be more complex than we think. Now, no one can deny that there
are a lot of problems. One of the problems is, is medicine able to
attract the best and the brightest anymore?

There was a time when people were very much attracted to medicine
because it was going to provide them with significant independence, they
didn\'t have to have 300 hoops to jump through in order to do what they
thought was the right thing to do, they thought they were remunerated
fairly, they felt that it was a very prestigious job.

I think that may have something to do with the change that we see in the
demographics of people who are going into medicine. Maybe that\'s good;
maybe that\'s bad. It\'s probably something that needs to be discussed.

Are the liabilities of practice too great? Are the tangible rewards too
small for the time and the effort commitment? If the answer to that is
yes, are there things that we should be doing to address that, and are
there consequences if we fail to do that?

Are there models that we can look at around the world, of places where
the tangible rewards for medicine were removed, and what happened in
those situations? Need we learn from those things?

Now, in terms of some of the many ethical issues, new knowledge and
technologies are certainly going to bring some new moral issues. For
instance, because we can keep people alive for 150 to 200 years, should
we do it? These are issues that the new professional is going to have to
face.

Should we choose a baby\'s sex because we have the ability to do that?
As medical professionals, are we servants of the client? Because they
decide they want to have a boy and we have the ability to insure that
they have a boy, should we do that, knowing what the long-term
consequences of those kinds of things are?

I think those are major ethical issues that we need to address with
students. Should we create organs, spare parts, and if so, to what
extent? Is it okay to create an eyeball but not a face? A kidney but not
an entire abdomen? I mean, where do we draw the line with these kinds of
technologies that will become available to us?

When we have the ability to bring a fetus to term outside of the uterus,
will we have to redefine viability? Another big one, when all
information is electronically and digitally available to us instantly,
what will be the role of memorizing things in medical education? That\'s
coming.

Now, there was a time also, just moving to another area here, when most
physicians gladly provided care for the poor. But that was a time when
they were fairly reimbursed by insurance companies, and there was the
ability to spread costs over a number of different people. That\'s no
longer the case.

I\'m reminded of a case just two weeks ago, a little girl from Maine who
had a very, very complex spinal condition. She has achondroplasia, has
been operated on a couple of times, and the problem is not going away.
It\'s going to require some very, very intricate surgery. But it\'s
going to require both my services and pediatric orthopedic services.

The patient is Medicaid of Maine. Their reimbursement is 5 percent of
the charge. I said I would accept the 5 percent. The orthopedic surgeon
involved said, \"Forget it,\" not happy. And I don\'t particularly blame
him.

But, you know, there was a time when if there was somebody who was
indigent, you could just say, \"Write it off. No problem.\" And you
wouldn\'t have a problem from the hospital because there was enough of a
pot of money, and nobody really got bent out of shape. It doesn\'t
happen anymore.

Medicare was supposed to help solve that kind of problem, and maybe
initially it did. And someone made mention of the fact that physician
reimbursements went up significantly when Medicare was first
established. That perhaps was the case, but at that point,
reimbursements from Medicare were significantly higher than they are
now. They\'ve continued to go down, and then other reimbursements have
been indexed to that.

So those are issues that can\'t just be discarded and not looked at in
terms of the impact that they have. And is there so much emphasis on
professionalism that we in the medical profession have dropped the ball
on finances, and allowed that to be taken over by other people, instead
of, you know, trying to take charge of that ourselves and perhaps making
sure that things are more equitably distributed, as opposed to putting
it in the hands of people who are business-oriented and are interested
in making money for themselves and really could care less about what
happens to patients.

And I would be the first to admit that the medical profession has
dropped the ball on that. But it may be not too late to pick it up
again.

Now, in terms of outside influences, research dollars are getting harder
and harder to find. And of course, that has led to the alliance with
industry---drug companies, device companies, in a very significant way.
And there\'s no question that that can have a deleterious effect.

But, can we just say, \"Stop it,\" and not have anything to replace it
with? And is there maybe a larger responsibility towards society to say,
you know, what those dollars from the drug companies are providing is
something that is important.

And is there another way that we can provide those dollars for that
research for the various things that need to be done? I don\'t think we
can just say, \"You guys are bad, all of you are bad, a curse on your
houses,\" and let it go away. It doesn\'t work that way.

Now, I\'m going to come back to the idea of our social responsibilities
momentarily. Now, there is significant blame to go around. Most
physicians find repugnant the incredibly large fees exacted by liability
attorneys, particularly malpractice attorneys.

But isn\'t it really just as bad from a moral and ethical point of view
for physicians to collect fees for treatment of hopelessly terminal
patients, when it\'s known that those are hopelessly terminal patients?
Doing procedures on them and collecting fees I believe is reprehensible,
something that we frequently just don\'t talk about. And I believe those
things need to be talked about, particularly in terms of looking at the
way that we can more equitably distribute resources.

Someone mentioned this morning --- no, it was actually mentioned in one
of the articles that we need to coax physicians into seeing uninsured
patients. Now, you know, that sounds nice. But we also have to look at
the practical reality that the people who are most likely to bring
lawsuits are those very indigent patients, looking at the statistics. If
we\'re going to be coaxing people to see these patients, we clearly are
going to have to re form medical malpractice.

Now, also, one of the articles talked about the importance of getting
the media to take a role in this. But the media, you know, I have mixed
feelings about the media and their responsibility.

I wrote a column for the Washington Post a few years ago about medical
liability and the fact that it always gets through the Congress, but
whenever it comes to the Senate --- it gets through the House, and
whenever it comes to the Senate, even though there\'s enough votes to
pass it, it never gets voted on because of a couple of filibustering
senators who are in the hip pocket of certain special interest groups.
And that the media has responsibility to shine the light on those
filibustering senators. But they haven\'t done it. So, you know, I just
wonder how reliable they would be in helping us with these various
problems.

Now, getting to the pharmaceutical companies, they\'re not all horrible
people. Some of them actually produce pretty good products, actually.
But I wonder if maybe they should be publicly graded, the same way
hospitals are, in terms of their relationships with the medical
profession.

They are exquisitely sensitive to public scrutiny and to their
reputations. And there may be ways that we can take advantage of that.
The ones who don\'t bribe physicians get an \"A\"; the ones who bribe
everybody get an \"E,\" you know. If this was done on a regular basis, I
think it could probably have some impact.

Now, moving to the residency issue, a few years ago, I think most of us
are aware of the fact that there was a major change in the hours. And
residents are now only allowed to work 80 hours a week. In certain
specialties they get an exemption and work 88 hours a week. That, along
with some other types of changes, have resulted in large part to a
different type of mentality when it comes to identifying patients as
\"my patient.\"

And there\'s more of a \"This is my shift\" than there is \"This is my
patient\" type of mentality. Now, I don\'t think that\'s going to go
away. But what we need to figure out is a way to work within that
framework to try to reestablish that relationship that I think was so
important.

When I was --- if I had a patient who was having a problem, there was no
way I was going to leave. I mean, I wanted to deal with that situation.
And I think most of us in the older generation probably felt that way.
And we\'re dinosaurs in that regard. But is there something that we can
do to help foster that type of relationship once again?

And another thing, physicians in training do tend to model what they
see. If you look at most surgical interns, they\'re very nice people ---
considerate, reasonable. And by the time they\'re chief resident, most
of them are not like that anymore.

Now, what happened during those years? Watching people yelling, throwing
instruments around and acting like they\'re God reincarnated. You know,
this is craziness. And yet, I see it tolerated, and it really should not
be tolerated.

We in medicine fall down when we do not call people on that kind of
infantile behavior, which is then re-modeled by those coming along. It
becomes sort of a rite of passage.

Also, should we continue to teach emotional detachment? We tell doctors,
we tell nurses in training, \"Don\'t become emotionally attached to your
patients, because you\'re going to burn out and because it\'s going to
be harmful to you in the long run.\" Now, I\'ve never discovered how to
do that, myself.

And does it hurt when something happens to one of your patients?
Absolutely. It\'s extraordinarily painful. But you can get over it if
you know you\'ve done your best. And, you know, I think we need to
reexamine that whole concept.

And finally, making healthcare affordable and available to everybody is
perhaps the biggest ethical issue facing our nation today. And I think
for a Council like ours, in terms of having some real, tangible
recommendations to make for the President and for the Congress, we
really need to be looking at what\'s wrong with a system that has plenty
of money in it, but has so much disparity in terms of the way that it\'s
distributed.

And, once again, thank you all for what you\'ve presented.

CHAIRMAN PELLEGRINO: Thank you very much, Dr. Carson. I will now open
the discussion --- Diana, you had your hand up first.

PROF. SCHAUB: I just want to say I\'m sort of surprised by the emphasis
on transcending self interest. I admit that there can be a conflict
between the patient\'s interest and the doctor\'s interest, but only
when the doctor isn\'t really a doctor. And I have a wonderful little
story that Booker T. Washington tells that I think illustrates this
point. It\'s just a couple of paragraphs.

In a certain community there was a colored doctor of the old school who
knew little about modern ideas of medicine, but who in some way had
gained the confidence of the people and had made considerable money by
his own peculiar methods of treatment.

In this community there was an old lady who happened to be pretty well
provided with the world\'s goods, and who thought she had a cancer. For
20 years she had enjoyed the luxury of having this old doctor treat her
for that cancer.

As the old doctor became, thanks to the cancer and to other practice,
pretty well-to-do, he decided to send one of his boys to a medical
college. After graduating from the medical school, the young man
returned home and his father took a vacation.

During this time, the old lady who was afflicted with the cancer called
in the young man, who treated her. After a few weeks, the cancer, or
what was supposed to be the cancer, disappeared, and the old lady
declared herself well.

When the father of the boy returned and found the patient on her feet
and perfectly well, he was outraged. He called the young man before him
and said, \"My son, I find that you have cured that cancer case of mine.
Now, son, let me tell you something. I educated you on that cancer, I
put you through high school, through college, and finally through the
medical school on that cancer. And now you, with your new ideas of
practicing medicine, have come here and cured that cancer. Let me tell
you, son, you have started all wrong. How do you expect to make a living
practicing medicine in that way?\"

Now, if the father is right and there really is this sharp conflict
between the patient\'s interest and self-interest, then it seems to me
our only hope would be to cultivate altruism.

But the father isn\'t right, and the point of the story is that the
father isn\'t right. The son is right. The son is truly a doctor, a
healer. And for the son it seems to me there is no conflict between the
good of the patient and his own self interest, because his self-interest
is the self interest of the doctor.

The quack, which is what his father is, lives often uneasily by duping a
few; the good doctor makes a reputation for himself, and by his healing
he lives securely and prosperously by serving the many. So I guess I\'m
just a little uncertain about all the emphasis on withstanding
temptation. It seems to me it\'s not really necessary if you understand
yourself to be a healer. In that case, your self-interest would not be
at odds with your patient\'s interests; they would coincide. You\'re
guided by love.

The man who loves his wife doesn\'t have such a problem with the
temptations of adultery. So it seems to me that what we need to think
about is, you know, how do the institutions have to be structured to
make sure that they don\'t undermine that love?

So calling on doctors to be professionals doesn\'t seem to me to be the
answer. I mean, no kid grows up wanting to be a professional. I can\'t
think of anything more deadly than being a professional. Kids grow up
wanting to be a doctor, wanting to be a teacher, wanting to be a
fireman.

So we need to figure out how to let doctors be doctors. And it may be,
you know, that there are all kinds of things in the institutions that
are interfering with that. But it seems to me when I listen to the
doctors here speak, when I listened to Ben Carson, when I listened to
Dan Foster or Paul McHugh, they really do embody this love.

CHAIRMAN PELLEGRINO: Do you want to answer?

DR. COHEN: A very interesting comment. With all due respect, I think
it\'s a semantic issue that you\'re raising. In your vernacular, I would
phrase it this way: what we want to do is convert doctors\' sort of
original self interest into the self interest of a doctor. So I don\'t
care whether you call it self-interest or patient interest.

And I agree with you, I think doctors should have that motivation
internally, strongly felt, voluntarily devoted to the doctor\'s sort of
profession. And that\'s what we\'re trying to do.

So I think it\'s a confusion of words here. I don\'t think we\'re trying
to avoid self interest. We\'re trying to convert the doctor\'s self
interest into being in harmony with what the patient\'s interest is.

PROF. SCHAUB: Yes, I guess --- I mean, it is a matter of words, but I
think the words really matter, and that you can actually undercut what
you\'re aiming at. I mean all the talk, for instance, about assessment.
I\'m in teaching, and we are also talking a lot about assessment and all
of these regimes of assessment.

It seems to me that in many ways that really undermines the enterprise.
I mean, I was struck by --- at one point, at page 614, you talked about
the bad apples, right? That there may be some way to sort of figure out
from a pretty early point which doctors, which future doctors, are going
to be problematic.

It seems to me it might make sense to put some real emphasis there. You
know, are there things that you could do to really figure out who
doesn\'t belong in this enterprise? But the other kind of assessment,
you know, constantly filling out forms and looking over people\'s
shoulders and all of that might actually undermine the love that real
doctors feel for their enterprise.

CHAIRMAN PELLEGRINO: Dr. Meilaender and Dr. Bloom, and Peter.

PROF. MEILAENDER: I\'m next? I want to express --- this is really in a
certain way a continuation of a comment I made in the previous session.
But I want to express just a certain frustration as I try to think about
what this Council could think about or could do. I\'ll try to do this as
compassionately and empathetically and so forth as I can.

But I\'m just puzzled by a lot of things. Doctors are supposed to place
the public interest above self-interest. Now, I mean, I\'m not going to
go the entire way with Diana\'s point, because a doctor is not only a
doctor. A doctor is many other things and so has other interests. I
understand that.

But Professor Rothman this morning told us how medical education,
medical practice, were being changed by the presence of so many more
women who weren\'t about to be told it was a 24/7 calling, and that was
evidently a good thing, I think, as far as I could tell.

But that didn\'t sound in some simple way like placing patient interest
ahead of self-interest; it sounded more like kind of sorting out life in
such a way that I looked after my own interests. But it was evidently a
good thing.

So I just think that this whole talk about interest is not clear. It\'s
muddied by, as I said in my comment in the earlier session, the kind of
language of altruism that hasn\'t been sorted out, hasn\'t been thought
through carefully. And we\'re not going to get anywhere until we get
clearer on what that is. That\'s one sort of comment. And until we can
do that, I don\'t know what it means to make patient welfare --- give
primacy to it. I just don\'t know what it means.

The loss of trust, which is evidently sort of the primary problem ---
and it may be. I don\'t know. I haven\'t done sociological studies.
Maybe it\'s the loss of trust in physicians. But what\'s the evidence
for thinking that the primary reason for the loss of trust is some
tendency of physicians primarily to pursue their own commercial
interests? I mean, maybe there is evidence, but I haven\'t seen any.
What is it?

My hunch would be that specialization has a lot more to do with it, in
the fact that you don\'t deal with the same physician over time and
therefore don\'t have the same kind of relationship that leads to trust.
Or it might be --- I mean, if I found out that my physician was thinking
that one of the primary aspects of his profession was a commitment to
social justice, I might start to worry that he was going to think about
somebody else\'s needs a lot more than mine, and I might begin to lack
trust in him.

So that these several claimed aspects of professionalism just don\'t fit
together for me. And then finally, it may be that we need to restructure
society in fundamental ways. And probably you always need to restructure
society in fundamental ways. But we\'ve got to have arguments about
this, and about how it\'s supposed to be done.

Not just general claims or assertions --- I just don\'t see where we as
a Council are going to get anywhere with just some sort of general
assertion. I mean, the same thing is true with respect to education.
There is an enormous disparity between the wealth that we have there and
the distribution of it. No doubt it should be altered in some way. But
how to go about that --- I mean, I can\'t imagine that just asserting
the fact is very helpful.

So I just think that there are a lot of particular examples we\'ve been
given that are persuasive and compelling, but I don\'t see that
theoretically we\'re getting anywhere or making progress towards
something that --- well, that we\'d have a contribution to make about
it.

CHAIRMAN PELLEGRINO: Dr. Bloom.

DR. BLOOM: I\'ll try to be brief, because I think we\'ve had three very
eloquent, well reasoned and clear discussions of what the issues are in
re-establishing a professionalism in the medical profession.

But it seems to me that if you listen with a filter for what is the
recurrent element that each of the three speakers spoke to, it\'s the
healthcare system that is causing the problem, and frustrating the young
physicians and developing the cynicism of the maturing physicians, and
in beating down those physicians who have dedicated their lives to
taking care of the poor.

The system is overwhelming the professionalism that was there at the
start. And unless we do something about the healthcare system, it\'s
going to be like the old joke about the honor system. The administration
has the honor, and the students have the system.

In this case, society has put us into a position where we cannot do what
we think is right. And if we don\'t stand up for telling the public that
what we\'re doing is pulling the wool over our own eyes by tolerating a
system that will not allow us to promote the health of our countrymen,
we\'re not doing good service.

We\'re in an election season. Healthcare has to be on the agenda for the
nation as a whole, and this Council ought to make statements about the
hypocrisy of our healthcare system. We have to acknowledge not only that
certain senators do it better than others, but that we\'re not allowing
the huge investment we make in healthcare to contribute to health. We
spend more of our gross domestic product on health than any other nation
in the world, and yet we rank very poorly on the health of our country.
That, it seems to me, along with the .789 in Jordy\'s talk about access
to care and universality of care and quality of care, is a much bigger
issue than trying to give pep talks to residents to maintain a
professional attitude in a system that we have tolerated for 25 years
that we know is going in the wrong direction.

MR. PELLEGRINO: Thank you, Floyd. Dr. Schneider.

PROF. SCHNEIDER: First a quick word on trust. The trust that patients
have in their physicians remains quite high, possibly because patients
have no choice but to trust their physicians. The trust in leaders of
medicine has gone down.

Of course, the trust in every human being in the United States has gone
down --- every profession, every business has lost trust. And if you ask
people, \"Do you trust people generally?\" they will say, \"Less than I
used to.\"

So, I think that looking for reasons in medicine for the decline in
trust in medical leaders is probably not a very fruitful activity. I
confess that I have tried to read these materials and some of the
supplementary materials that were referred to in the materials, and
I\'ve listened to the conversations this time and last time. And I feel
as though I am swimming in cotton candy.

This conversation is being held at a level of such abstraction that I
have no idea what\'s going on. I passionately agree with a lot of the
things that people have said about how wonderful the ideals of medicine
as a profession can be, and for that matter, of lots of other
professions.

And yet I find the conversation taking place in terms of this word
\"professionalism,\" which has no meaning at all. It is used by every
group that wants to be better regarded and better compensated. And it is
used as a way of fighting all kinds of battles without actually coming
to grips with what\'s actually going on.

In search of guidance, I read the Physician Charter, and I have to say
that I found it absolutely incomprehensible. It, too, is phrased at such
a level of abstraction that you can\'t disagree with anything in it, but
you can\'t tell what anything in it is actually going to mean when the
rubber hits the road.

I find myself confused because the conversation is at such a level of
abstraction that I don\'t know what the actual evidence is that things
are so bad or things might be so good.

I read the description of what life is like in medical schools because
of the abominable way that many faculty members behave, and I looked to
see what the citation for that proposition was, and it was another
article that didn\'t have any actual evidence, but just said, \"Things
are terrible.\" So I don\'t know what the actual empirical dimensions of
things are.

Then we have been talking in terms of another set of abstractions, this
abstraction about the contrast between commerce and professionals. And
it seems to me that that discussion has been made almost exclusively in
caricature.

I know lots of business people who have better ethics, a better sense of
responsibility, and care more for their clients than a lot of members of
professions do. And a number of people have said about professions that
they have behaved in ways that have caused them to lose trust.

I do want to say about the trust, remember that in 1909 Bernard Shaw
said, \"The medical profession has not a high character; it has an
infamous character.\" In 1978, a political scientist wrote, \"There are
widespread complaints against the medical profession on the grounds both
of failures in the realm of service to the public and of defects with
regard to effective self-regulation. This is 1978, remember. \"The
public dislikes the way physicians often seem to be concerned more for
science than for caring, to have turned their means into ends, to have
become authoritarian and unresponsive,\" and finally, \"to care too much
about their money income.\"

So, this idea that somehow, if we just abandoned this bad thing that is
called commerce and went to this good thing that is called
professionalism, then all would be well, I find operating at a level of
caricature that I don\'t think is very helpful.

I also think that it\'s important that we be more precise about the
historical moment and about something that I think we have almost not
heard discussed at all, which is the role of the organized profession.

And I keep saying \"profession\" instead of \"medicine\" or what have
you, because I regard all professions as conspiracies against the laity,
as Shaw said some years ago. I know of no profession that runs itself in
a way that we ought to admire.

But let me talk more particularly about the role of organized medicine.
The definition of professionalism we hear is a definition that talks
about the importance of service to others and to the welfare of the
patient.

But organized medicine, which ought to be more interested than in
anything else in seeing to it that all Americans actually have some way
of acquiring medical care --- organized medicine has fought proposal
after proposal after proposal for some way to fund it. They, you
remember, opposed Medicare and Medicaid. They called it socialized
medicine.

And organized medicine continues to play a role in these professionalism
issues that seems to me to be highly destructive. The conversation that
we\'re implicitly having seems to me to be in large part about managed
care. When we talk about how hard it is now to practice medicine
properly, I take a lot of that conversation to be a conversation about
managed care.

And it may well be that managed care is a dreadful thing. But let\'s
remember how we got into managed care. We got into managed care because
after Medicare and Medicaid, the fee for service system got more and
more out of hand, and it became impossible for us to feel that we could
continue to pay for medical care.

And in an attempt to try to control those costs, we moved to managed
care. It may well be that managed care isn\'t the right way to do it.
But the difficulty that I have here is the difficulty that I have in
many aspects of the way that organized medicine has dealt with these
problems.

Organized medicine has not come up with a good substitute for managed
care. It has said, \"Things are bad. Stop hassling us.\" Organized
medicine has not come up with a good way of providing care for poor
people. It has just said, \"We\'re against every proposal that you have
put forward.\"

I not only looked at the manifesto for---that\'s not a good --- the
charter for medical professionals, I looked at the article about the
alliance between society and physicians, which amplifies the charter.
And it seems to me to carry on in this vein.

It says, \"Yes, we\'re in favor of all of these altruistic things, but
you\'ve got to remember we need to have enough salary or enough income
so that we\'re not unduly tempted.\" I find that deeply embarrassing.

Right now, house-sitting for us is one of my neighbors. I live in a
working class community, and my neighbors would feel very lucky to make
the average American household income, household income, not individual
salary, which is about \$50,000.

And my neighbor is sitting in my house, and I expect him --- he seems to
be operating under much more temptation than a physician has. I expect
him not to steal from me. And I think we expect the maids of this hotel
not to steal from us. And I think that it\'s clear that there are people
who live under much greater kinds of temptation.

So to begin this discussion by talking about the need to pay doctors
enough that they\'re not tempted to behave unethically strikes me as
very troublesome. The alliance paper then goes on to talk about in
extremely colorful terms how impossible the legal system has been, and
it talks about the need for doctors to be able to maintain individual
and professional autonomy.

If you look at that through the kind of historical lens that I\'m
talking about, what it looks like is another attempt by a profession to
say, \"Do not regulate us, but let us continue to control ourselves.\"

Now, that leads me to what seems to me to be one of the most egregious
failures that all professions display, which is a failure to deal with
their incompetent and unethical members. It is absolutely plain that no
profession I\'ve ever heard of is willing to take that job seriously.

And one of the problems I have with the discussion we\'ve been having
and with the charter of professionalism and all the rest of it is that
nobody has ever talked about how it is we\'re actually going to enforce
any of these ideals.

We are supposed to be moved by the loftiness of the ambitions, and I am,
but I want to know how it is that we\'re actually going to deal with
people who don\'t do the right thing.

That leads me --- and I\'m coming to a close pretty soon --- that leads
me to what seems to me to be a temptation of all professions---it
happens in law --- to say, \"Oh, my God. Things are terrible here. What
we have to do is to tell the medical schools and the law schools that
they have to educate people better and all will be well.\"

The first thing that\'s wrong with that is that I don\'t think I\'m
going to live long enough to have all of the unethical doctors and
lawyers pass through the system to be replaced by the newly educated
doctors and lawyers who understand how to behave ethically.

The second problem I have is that it is just grossly implausible that
any kind of activity in a professional school is going to make
professionals behave well if they get out into a world in which bad
behavior is beneficial to them and good behavior is costly.

If there is one thing that psychology has discovered about human
behavior, it is that character matters surprisingly little, and that the
circumstances in which you find yourself matter a great deal.

I\'m sure you all know about the Milgram experiments, where they took
perfectly normal, decent residents of New Haven and induced them to, in
the understanding of the research subjects, to give terribly painful
shocks to apparently perfectly innocent people.

And this kind of experiment has been duplicated all over the place, and
it represents a very standard understanding that you can make people
virtuous in character all you want, but that their actual behavior is
going to be very strongly influenced by the circumstances in which they
find themselves.

Let me suggest one way in which education, if it really wanted to take
professionalism seriously, might do it. And that is by disciplining
their students. If it is true that 97 percent of the people who enter
medical school leave with MDs, then it is clear that that is not what
they are doing, that they are not taking this seriously.

And I\'m certainly here to tell you that law schools do not deal with
their inadequate students in any way that suggests an actual interest in
encouraging professionalism or in deterring misbehavior.

I actually spent last semester visiting at the Air Force Academy. And
one of the interesting things about it was that that is an organization
that actually does care about professionalism --- being a military
officer being one of the original professions.

But they believe that in order to make education effective in
encouraging professionalism, you have to make that a primary activity.
So the motto of the Air Force Academy is \"Integrity first.\" \"Service
before self,\" second. \"Excellence in all we do,\" third. But integrity
comes first.

And \"Integrity comes first\" for them means that if you lie, cheat or
steal, or tolerate somebody who does, you throw them out of the Academy.
And it is by that kind of clear statement that you really mean this and
you\'re not just adjuring them to behave better that you have any hope
of having education make any kind of difference.

So I wind up truly hoping that if we move in some direction that we
speak with enough concreteness and clarity that we do not become one
more statement of high ideals.

CHAIRMAN PELLEGRINO: Let me mention that we\'re reaching the end of our
time, and what I will do is the following. Peter, obviously, you make
your comment, and if anyone wants to make one more comment, then we\'ll
have a break and we\'ll come back and give our speakers an opportunity
to respond.

And I don\'t mind cutting into time allotted to me. So don\'t worry
about that. And I\'m sure you\'re not worried about it anyhow. You
wanted to get on the list, Dan? Okay. And we\'ll open the list again
when we come back. But I\'d like Peter to make his comment if he would,
and then if you don\'t mind, we\'ll take a break and you both respond.

Are you in a rush?

DR. COHEN: I\'ve got a 6 o\'clock flight.

MR. PELLEGRINO: All right. We\'ll give you a chance to respond, if the
group doesn\'t mind. Peter.

PROF. LAWLER: All right. I\'ll make this as brief as I can. I certainly
can\'t follow that. And I\'m not an M.D., and on all of these issues I
don\'t have a strong opinion. I am though, in the profession, such as it
is, of political science. And here are some irritating words that have
snuck into the profession of political science, coming from academic
administrators.

\"Civic engagement,\" \"social justice,\" \"social activism.\" Now in
the opinion of deans and other administrators, the most important thing
in political science is to inculcate in students passion and purpose. In
other words, get them out there being all activist about everything in
some sixties manner, without asking the question, \"Do they have any
idea what they\'re talking about?\"

So actual education is subordinated to activism and engagement. So when
I think about a physician, I wonder how much this really has to do with
the job of a physician. In my county --- quickly---we\'re a regional
medical center. We have more physicians than any other county in the
country per capita.

Not only that, studies have shown that physicians in our county enjoy
the highest standard of living, relative to the local standard of
living, of any county in the country. So our physicians are as happy as
physicians can be nowadays.

As a result of that, many of our community leaders are physicians, and
they do many admirable philanthropic things, as Dan does and as so many
of our---as Ben does, and the other physicians on our Council do. But
I\'m not sure they do these things as physicians. They do these things
because they\'re good guys, they make the big bucks, and have some extra
time. I\'m for them doing this.

And some of them are involved in politics. Some of them get elected to
office. They have all sorts of political opinions. But their political
opinions are not particularly good because they really weren\'t trained
to have good political opinions, nor would an extra course in their
medical education really have helped out there all that much.

In fact, many physicians in my area disagree with many of the things
that have been said here. They are radically libertarian. They believe
that the problem of access could be solved through a lot more market,
not less. I tend to think they\'re probably not right, but I don\'t
think they really know whether they\'re right either.

So our physicians have all sorts of political opinions. They\'re all
over the map. But some of the writing --- and I think in a certain sense
some of the presentations---suggest that physicians as physicians have a
particular conception of social justice that unites them together in
this particular agenda they should push together as physicians. I just
doubt that this is really so.

DR. FOSTER: I just want to make one sentence in defense of physicians
and residents. I\'ve just come off the wards at Parkland Hospital. I
think that this crisis in professionalism is at least something that I
don\'t see working on the wards. I think the students that we have now
are enormously admirable, both in terms of their talents and dedication
to science and in their kindness in taking care of the poor.

And I\'d say one other thing. Almost every one of the --- I would be
happy to have almost every one of the senior residents at Parkland
Hospital take care of me now, or my family. I just want to say a word
about --- I don\'t think that --- it\'s just not the picture I have of
the crisis of loss of altruism or anything. And I\'m only talking about
one place, and maybe you might think that I\'m too much of an optimist.
But I just got through with this, and I\'d let them take care of me
right now.

CHAIRMAN PELLEGRINO: Jordan?

DR. COHEN: Well, let me make a few comments, if I could, in response to
some of the things that have been said.

Let me start with Dr. Carson\'s comments. Two things I want to comment.
First of all, I think your notion about the selection of students is
right on target, as I tried to mention. And one of the things I didn\'t
mention that I think is important is the way in which schools project
what they\'re interested in to prospective students.

And I think there is altogether too much --- the perception is that
we\'re interested only in grade point average and MCAT scores and not
interested in these issues of character and commitment to service and
what have you.

As a consequence, I think --- and again, I have no evidence for this but
this is my strong perception --- that a lot of students who I would very
much love to see in medicine would even be more impressive to you, Dan,
than the ones that you are now dealing with, never even choose to apply
to medical school because they don\'t think that\'s what we\'re
interested in, that we\'re interested more in what\'s in their head than
in their heart.

So I think one of the jobs of medical schools is to be more
explicit---to the degree that they believe this, which I think they
do---but to be more explicit about what they really are looking for in
applicants, that these are as important characteristics as long as they
have the scholarly and intellectual capability to meet the challenge.

And several of the points you made and several of the points I think
that Dr. Meilaender made as well I think relate to this issue I ended my
comments with, namely, that to the extent, again --- and you may not
agree with this; from your comments I\'m not sure you do --- that the
public does have a stake in doctors and the profession adhering as best
they can to this ethic of service to the public.

That to the extent that there is a commitment to that kind of
service-oriented value system, the public gains a great deal. In the
absence of that, there would be much to be lost. Now, you either accept
that premise or not.

But if you do, then it seems to me that one has to take cognizance of
the fact that there are a number of things, as I tried to indicate, and
which that alliance paper spells out, that the profession cannot grapple
with unilaterally. It requires some kind of interaction with the
policymakers or the lawmakers in order to address the access issue.

We can\'t solve the uninsured problem as a profession. It requires that
we convince the policymakers that they\'ve got to get in bed with us and
lead with us and solve it. We can\'t behave the way we want to behave in
the absence of access to care, in the absence of the ability to do the
quality of things and all the other things I mentioned.

And again, on this topic, Dr. Meilaender, I\'m really sorry that I think
you misread that aspect of the alliance paper that spoke about physician
payment. It\'s not that we\'re looking for more money; it\'s the
mechanism of the reimbursement system that is not properly aligned.

I wouldn\'t have any problem with there being no more or even less money
available for physician services. But the way it\'s currently committed
to the profession, it doesn\'t reinforce the attitude of patient
interest primarily. The fee-for- service system in my view is
antithetical to a profession that truly is acting in the interests of
the public and patients.

You can\'t expect doctors, particularly with the disparity in the
fee-for-service as it currently exists, to avoid that temptation. It
seems to be more than one can honestly expect even of a highly motivated
physician, to adjure self-interest when they\'re faced with that kind of
temptation.

So that\'s the point that I was trying to make there, not that doctors
want to make more money. It\'s just that the mechanism of payment is not
properly structured to deal with these issues.

CHAIRMAN PELLEGRINO: All right. I think we\'ll take a break until 4:20,
and then return and give Dr. Leach a chance to respond, and further
questions you may want to raise or contribute.

(*Whereupon, the proceedings in the foregoing matter went off the record
at 4:10 p.m. and went back on the record at 4:25 p.m.)*

CHAIRMAN PELLEGRINO: What we\'ll do from this point on is ask Dr. Leach
if he wishes to respond. If others of you have other questions, let\'s
not repress them. We\'ll continue, as I think the discussion is going in
a very --- how shall I put it --- interesting manner, and we should
continue it and try to explore some of these issues further.

Don\'t worry about cutting into my time. I\'ll get a few one-liners in
somewhere along the line.

DR. LEACH: Thank you very much. I\'ll be brief. I have to, not for lack
of interest, but because I have a plane to catch. Something very
practical that you\'ve been calling for has occurred, and I have to
catch my plane.

I would encourage all of you to listen to Dr. Carson. I agreed with
everything he said. He mentioned information systems and what patients
would do when abundant reliable data became available. I\'ve thought
about that a lot. And it seems to me there are three reasons why a
patient would continue to go to a doctor.

One is that unlike the computer, the doctor shares a human vulnerability
with the patient. Both are going to die; both are going to suffer. And
that\'s comforting when you\'re sick, to be in the presence of a fellow
human. If that\'s true, then the educational programs should encourage
one to become more fully human.

I think a second reason is that I have a friend, David Stevens, whose
wife is a musician, who is a physician. And he woke up with severe pain
in his joints and a little rash in his popliteal fossa. His wife, with
no medical knowledge, got on the computer and discovered that the rash
on his popliteal fossa looked exactly like Lyme disease.

So, totally naive, she said, \"I think you\'ve got Lyme disease and we
should get some doxycycline.\" And she marched him to the internist and
walked in and said, \"David\'s got Lyme disease. He needs doxycycline.\"

And the intern said, \"Well, that\'s very interesting. We\'ll have to do
a few tests.\" And she said, \"Tests are not helpful in the early phases
of Lyme disease. He needs doxycycline.\" And he got it and was cured.

Well, that reminded me of a second reason why people would go to
doctors. \"I think it\'s Lyme disease, but I don\'t know. Perhaps
you\'ve seen a case. Maybe you can recognize this pattern.\" So, in
addition to training doctors to be human, we should train them to
reflect on their practice, accumulate their experience, and learn how to
discern early pattern recognition.

And lastly, if you\'re going to have your brain operated on, not
everybody can do that or prescribe certain drugs and so on, and they
would go to actually get that done. So those are three reasons why
patients would continue to see doctors in the information age.

I think the system should acknowledge the importance of those three
things and pay attention to them. Right now, you know, it is said that
every system is perfectly designed to produce the results it\'s
producing. And the system is producing the results it\'s producing.
It\'s producing things we like and things we don\'t like.

So, the inordinate expense, the inadequate results, it\'s designed to do
that and so it\'s doing that. Now, you could --- perhaps it\'s
dignifying healthcare to call it a system. It is so fragmented, it\'s
not really a system. But the thing that we do call \"healthcare\" is
demonstrating abundant opportunities to improve, that are going to
require redesign. And perhaps some of those issues are important for
this Council.

Residents became stressed, as did the whole healthcare system, when
basically three things happened: one, because of DRGs, time was
compressed. When I was trained, I had typically two weeks to get to know
the patient, and that was all. It was a true relationship. Now they\'re
in and out in a day and a half. And the resident\'s life consists of
admitting, discharging, admitting, discharging, admitting, discharging,
on a treadmill. It\'s a different lifestyle, one that challenges ethical
principles. There\'s more to do.

When I was a resident, if you wanted to know how the patient was doing,
you had to go and talk to the patient. Now you fill out forms to get
tests done that are helpful, but it consumes all of the available time,
and you don\'t talk to the patient. It\'s part of the system.

And lastly, there\'s less help. There are fewer nurses. So residents are
doing more in less time with less help. And, in that environment we\'re
trying to say, \"Be ethical.\" It\'s a stress.

Someone mentioned, you make residents virtuous. That\'s not the way it
works. It\'s educing virtue; it is taking what is latent and encouraging
and allowing it to emerge. It\'s tapping into their fundamental human
goodness and creating an environment that that happens. And I think
it\'s important.

And lastly, I think this Council is wonderfully diverse. And there\'s a
price with diversity, and that\'s conflict. And vision is a physiologic
hallucination. So there are billions of photons hitting my retina right
now. I can\'t possibly process all of them equally. I would go insane.
Based on my background and my experience, what I have discerned in the
past is important or not, I scan a room and see things, and then
there\'s a whole bunch of stuff I don\'t see, because I have not thought
it important. As I heard your comments, I was reminded of that.

When two smart people who care about an issue are arguing, it\'s not
that one is right and one is wrong; it\'s that both are blind. And this
Council and your report is going to help do something. You have to honor
and deeply understand each other\'s perspective, and that\'s, from my
point of view, the work before you.

I have to go catch a plane. Thank you very much.

*(Applause.)*

CHAIRMAN PELLEGRINO: Any comments, questions? Robbie, you look like
you\'re about to ask one.

PROF. GEORGE: Well, I was struck, as I\'m sure many were, by the
powerful condemnation that Dr. Leach offered in his prepared remarks of
the postmodernist view of life as denying any objective basis, denying
that there is any moral truth.

And anyone who has spent any time in universities in the last couple of
decades knows that that is not only a prominent view, but in very many
places, almost an established orthodoxy from which dissent is
remarkable.

Now, if Dr. Leach is right, and I have every reason to believe that he
is, that this has an impact on how young people who are educated and
socialized in our system, both in our high schools and colleges ---
because it\'s now filtered down into high school certainly --- if he\'s
right, that that has an impact on how people come to terms with the
demands, the ethical demands of their professions, then it is a serious
problem.

And it\'s not a problem that can be dealt with by professional ethics
courses in medical schools or law schools or what have you. It\'s a
socialization problem from the beginning. And what it does is, I think
it --- again, if Dr. Leach is right --- it means that we\'re not going
to solve this problem unless we take seriously the problem of a certain
ideology having such powerful standing in the intellectual culture.

Now, I\'m sure this Council doesn\'t want to get into the question of
postmodernism and its ideological hegemony or anything like that. But it
might be that anything else is really kind of tinkering around the edges
or rearranging the chairs on the deck of the Titanic.

I know Dr. Leach has to be right, it seems to me, about this. You cannot
preach to young people that there is no truth, that it\'s all socially
constructed, that all we have are moral opinions, there\'s no such thing
really as right or wrong on one set of issues, issues about sexual
morality or drug-taking or the sanctity of human life or whatever, and
then turn around and, with respect to questions of social justice or
professional responsibility, there is an objective truth that is
rationally accessible and which can be imposed on people if they are
recalcitrant about living up to it in their professional lives. I mean,
that kind of a mixed message just can\'t possibly work.

So I was very powerfully moved by what you said. It certainly resonated
with my own experience with 22 years of college teaching and a few years
before that in the universities as a student. But it does leave me
deeply wondering whether our problem is not deeper than what can be
addressed by any systematic shifting of systems and rules. That it\'s
really a deep problem in the intellectual culture. And I thank you for
what was really powerful testimony in two senses.

CHAIRMAN PELLEGRINO: Thank you, Robbie. Do I see a hand?

DR. HURLBUT: Do you have time for a question, or do you have to run to
catch your plane?

DR. COHEN: Ask me your question and I\'ll let you know. No, no, we have
a couple of minutes.

DR. HURLBUT: Just briefly. You talk about the outer leaves of the
lettuce, and my question this morning is the same basic question. Is it
possible that the role of medicine, the deep professional purposes, the
star we navigate by, is somehow lost?

Is it because of just what Robbie has affirmatively said, that because
we were criticized for being overly paternalistic, we shifted toward
relativism, that we gave up some of the longstanding principles of our
code in the face of the rising social acceptance of practices like
euthanasia, abortion, the confusions of modern biotechnology? I just ---
give me one minute.

I\'ll read something that troubles me very much, and I\'m just putting
this out. This is a quote from Margaret Meade, taken from a book called
The New Medicine by Nigel Cameron. He says that at the time the oath was
articulated --- and there may have been a period of time obviously ---
that the practices such as euthanasia and abortion were common. These
were accepted practices; they were not just considered evil, that there
was a real revolution in the Hippocratic oath.

Margaret Meade, who is not generally considered to be a conservative
Republican or whatever you want to say, she says, quote, \"The
Hippocratic oath marks one of the turning points in the history of
man.\"

She writes, \"For the first time in our tradition, there was a complete
separation between killing and curing. Throughout the primitive world,
the doctor and the sorcerer tended to be the same person. He with the
power to kill had power to cure, including specifically the undoing of
his own killing activities. He who had power to cure would necessarily
also have the power to kill.

\"But with Greek Hippocratism, the distinction was made clear. One
profession, the followers of Aesculapius, were to be dedicated
completely to life, under all circumstances, regardless of rank, age or
intellect. The life of a slave, the life of the emperor, the life of the
foreign man, the life of a defective child.\" And then she goes on to
say, \"Speak of this as a priceless possession which we cannot afford to
tarnish.\" Now, I just threw that out because, as Ben articulately said,
we are facing challenges, projects like fetal farming and so forth. If
we\'re really going to get down to questioning professionalism, it seems
to me we have to look at --- you said it very directly. Is it deep
hunger to return to classical medical values?

Is it possible that some of the outer layers on the lettuce are modern
aberrations of understanding of what professionalism really is, and that
the core problem in our profession may not be commercialism, self
interest, or all of these things, but that we have lost the guiding
principle that is fundamental to our profession?

I really didn\'t put that out with an agenda of assertion so much as a
question.

DR. LEACH: I think that\'s exactly the right question. And I think the
substrate of medicine, seeing people when they\'re sick and vulnerable,
you either support human life and its dignity or you go into some other
profession. I mean, it is a fundamental human activity.

And that is why I think the great strength in response to this --- I
don\'t know whether this is a crisis or not. I think that there\'s been
erosion of some traditional values. Young people and faculty live in a
postmodern world. It has had a set of assumptions that have not always
been carefully examined.

Having said that, I do not think this is a political argument, you know,
for abortion/against abortion. I think that justice and mercy kiss. And
I think a good doctor defends life and has mercy and has great
compassion for the patient\'s circumstances and doesn\'t compromise or
increase the patient\'s vulnerability by a political agenda. It\'s
deeper than conservative or liberal.

And to me, yes, I think --- and of course, this is a horribly mixed
metaphor --- the lettuce leaves are brown, a few of them. It\'s not
strip them away. The potato may or may not be sound. That is the
question. If the potato is sound, we will get through all kinds of this
and many other changes in the forms of medicine. If the potato is not
sound, we\'re dead.

And so to reinforce that at all levels of the educational system and the
practice world means you have to have an understanding of what a healthy
human set of values looks like. And that has to be the organizing
principle, as you adapt to the thousands of unique patients that come
with particular problems.

You can\'t look that up in a rule book. You have to have a good heart to
manage that. And that\'s what professionalism is all about.

CHAIRMAN PELLEGRINO: Further questions?

DR. ROWLEY: Would you comment again on one of the things that Ben said,
which was that physicians are trained to be emotionally withdrawn, or
detached from patients, and that maybe this is a bad thing? I\'d be
interested in your views on that.

DR. LEACH: And don\'t forget that he also said he could never do that.
Which I think is the mark of a good doctor. But it is true, and I think
--- I mean, it began long before Osler. But Osler said equanimity is
what you have to offer patients.

So when the world is coming to an end and everything is panic, if a
doctor can stand in full equanimity, which does require a wonderful
honoring of both arms of a paradox --- detachment enough to have
equanimity, engagement enough to actually help. And you cannot dishonor
either arm of the paradox.

But you do have to hurt people sometimes to get them better. I mean,
when Dr. Carson operates, it hurts. I wouldn\'t want an operation on my
brain.

DR. CARSON: We have anesthesia.

DR. LEACH: But then so you have to be able to say, \"Yeah, I\'m going to
cut your head open, take the bone out and put it --- yeah, I\'m going to
do all of that.\" And you have to do it well, and you have to do it in a
balanced way. And so you have to be a little detached to do that. You
wouldn\'t do that with your neighbor on a Saturday afternoon.

But you also, if you\'re a good doctor, don\'t let the detachment get to
the point that you don\'t give a damn. You constantly are supporting the
needs of the patient.

CHAIRMAN PELLEGRINO: Again, thank you very much for joining us. Well,
there are a few minutes left.

DR. ROWLEY: Well, I was just going to say that since this is an area in
which you have thought about a great deal, speaking for myself, I would
really like to hear what you have to say on the issue. And I don\'t
think you should cut your remarks short. I am perfectly happy to go to
dinner later or whatever.

CHAIRMAN PELLEGRINO: Well, I won\'t take all the time. I mean I will not
give the remarks that I had in mind. But I will make a few ---

DR. ROWLEY: The whole point of what I said was that you should give the
remarks that you had in mind. And just go on.

DR. KASS: I think Janet is right, Mr. Chairman. I would second what
Janet said. I think we really need to hear it.

CHAIRMAN PELLEGRINO: Well, let me make a few comments. First, all crises
are not bad. If you will remember the dictionary definition of a crisis,
so far as medicine is concerned, it has to do with an old observation we
used to make --- I think Dan even may be too young for it, but I\'m not
--- of the patient who developed pneumonia, and we didn\'t have any
antibiotics --- I date back before antibiotics --- and the patient would
go through a crisis. And the crisis would mean either death or recovery.
And we would always wait for the crisis somewhere between seven and ten
days with pneumococcal pneumonia.

I don\'t know whether you will decide that medicine is in crisis or not
to respond to Carl\'s question of last time. But let me give you a few
crises in medicine, just to raise some hope in this discussion, which
has had a lot of --- some dismal qualities to it with respect to the
future of medicine.

The Hippocratic Oath, which has been mentioned, arose at a time of
crisis. The Greek medical profession was in total disarray. They were
considered mostly quacks and money grubbers. And the Hippocratic
physicians who created the Oath stepped back and said, \"No, we don\'t
want to be like those people.\" And they developed an oath of
commitment.

Let me give you two or three more of those, and then I\'ll move on to
what I want to say.

A similar situation occurred in the first century A.D. when the word
\"professio,\" the first use of the word \"professional,\" which we\'ve
been throwing around here today, was made by the physician of the
Emperor Claudius.

And he talked about \"professio,\" the Latin word, strict word, of a
commitment to what? The Hippocratic Oath. And he made it in a treatise
which was dedicated to the fact that giving medication to people would
be in their interest, but he justified it in terms of the profession of
the physician, the promise, the declaration --- that\'s the etymological
meaning of the word --- was in fact to act in the best interests of the
person. And at that point, people were not doing it. So that was a
reform.

1803, the reform of Thomas Percival --- when the physicians of the
Manchester Infirmary were in a state of tremendous strife with each
other --- the Thomas Percival Code, which is the basis of the AMA\'s
code.

In 1857, the medical culture in the United States was in a terrible
state of distress, with the same kind of nonsense that was going on with
the Greek physicians, and we got the AMA Code of 1847.

You\'re all familiar with 1910, when Simon Flexner had the comment on
the dismal state of American medical education, 450 schools, and the
conception of scientific medicine was a single microscope, which usually
wasn\'t in very good operating condition.

I think we\'re in a similar situation now, where the profession once
more is in a state of confusion and identity in its relationship to
society, its patients to itself, and so on. And I\'m hopeful, can you
imagine, in the face of all of this, that we may get another kind of
reform.

Professionalism is one of them. I do not think the Physician\'s Charter
is the answer. I think the Physician\'s charter is admirable. It
describes a series of characteristics, of attributes --- ten of them, as
a matter of fact --- which we should have. But unfortunately, it is
ascriptive, it is descriptive, it is not argued. And medicine is at
essence a moral enterprise. It may not be conducted that way, but
there\'s no way of avoiding it.

And let me then pick up that theme and carry it a little bit further in
relationship to what is happening. Now, you will find a lot of this in
the paper I submitted to you, and I don\'t want to repeat that for you.

But fundamentally, I think if we are ever going to understand what\'s
happening, it\'s going to have to be in terms of what makes difference
in medicine. What kind of human activity it is which makes it different
from other human activities.

Not that other activities haven\'t the same kinds of dimensions of
morality put on them, but in medicine they are specific. And that goes
to the fact that each and every one of you is going to be on the gurney
one day. And I\'d like you to put yourself in that position, if you
would. You\'re on the gurney.

You may be healthy now, but I assure you, I\'m sorry to say it, you\'re
all going to be lying flat. And there\'s something about the horizontal
position as opposed to the upright position that I\'ve discerned in 66
years of medical practice that makes a difference in the way you look at
the world.

And so I\'ve concentrated in my whole notion of how medical ethics has a
special characteristic, which people have been pleading for, it\'s
related to what will never change, as far as I\'m concerned. When you
are on that gurney, you\'re no different than the sick patient
Hippocrates had, than the sick patients we have today, or, I can assure
you, when you get on the starship to Galaxy 999, it\'s going to be the
same. You\'re going to be dependent, frightened, anxious --- each and
every one of you, no matter how intelligent, no matter how courageous
you are, you\'re going to be in need of help. I use the word \"healing\"
without apology.

You will need healing, \"healing,\" being made whole again, which is
what the Anglo Saxon word means. Whole again to the extent that we can
do it, obviously. Not completely, but to try to repair, help, care, and
when we can\'t cure, to care, to comfort. You\'re going to need that.

Now, in that existential state, I the physician come to you and I say,
\"Can I help you?\" \"What can I do for you?\" What are the expectations
you have when I do that? You have at least two, I feel, and I think you
wouldn\'t disagree with me on that. One, that I\'m competent, or the
whole darn thing is a lie, my offering to help you, to heal you.

And the second one is that I\'ll use it in your interest and not my own,
and I won\'t exploit you. Now, you will say, \"Well, this is terribly,
terribly fundamental. It\'s obvious.\" It\'s so obvious that it\'s
painfully the thing that\'s most frequently missed.

Because, profession --- go back to that word \"professio\" of Stravonius
Longus and those before him, that act of profession is a promise, a
public declaration, in terms of the Latin etymology of that word, which
is still important, that I have the knowledge and I offer it to you, and
you have the right to expect me to use that in your interest. And that
is the bond of \"professio.\" That\'s what a profession means in
medicine.

In law it\'s another thing. In law they come to call and they\'re
looking for some repair of justice. And he promises, too, to take their
case. The minister deals with this. So what I\'m saying is common to
other professions.

I\'m not expecting uniquely to medicine, except that in medicine we have
the most intimate of human relationships, except those of husband and
wife, which you mentioned. And friendship, perhaps. But nonetheless, one
in which you must bare yourself. You\'ve got to take your clothes off.
You\'ve got to bare what\'s going on in your mind. You\'ve got to tell
about all the nasty functions of your body. That\'s a relationship that
doesn\'t exist elsewhere.

Ben has it in one dimension of his life. I as an internist have it in
most of them. I can\'t do what Ben can do to heal, but also, I can, on
the other hand, fulfill that compact. So it\'s a covenantal
relationship. And therefore, I think the obligations of medicine arise
from that.

Fidelity, trust, that\'s being a professional. Competence, that\'s being
a professional. That\'s why those adjectives are listed. But I find it
unfortunate they\'re listed as an answer to the problem by ascription,
by assertion, without moral argumentation. So I\'m looking for a moral
foundation for, if you want to say, re-professionalization.

I don\'t like the term \"professionalism.\" To me it has a connotation
of belonging to a group, a loyalty to the group, a certain amount of
elitism that we are professionals. I want to say the professional is the
one who makes an act of profession to another human being to act in
something other than his or her self-interest. And de-professionalism
means a default of that promise. It means failure to keep that promise,
and that\'s where the difficulty arises.

So that when you do come to the Botox dermatologist that was mentioned,
that\'s really a failure. Now, therefore, from my point of view, what
can we do? This is what you\'re asking, how we can change this? I don\'t
think any program is going to change it. I don\'t think any system is
going to change it.

I believe, with those of you who have raised questions about an
educational program, yes, it\'s useful, raise sensitivities, et cetera.
But I have been teaching for 65 years to medical students, and so far as
I\'m concerned, to learn something about this in the first two years of
medicine is hopeless. It has no connection for them with reality. Third
and fourth year it begins to impinge on them. And the residency is when
it really, really happens.

Now, I don\'t want to go into all the details of how one might teach it.
I have to shorten my comments. We are at 5:00 o\'clock.

But I want to summarize by saying we have not, in today\'s discussion,
gotten to the core, which is the human relationship, the very intense
human relationship, between someone in this very vulnerable state, this
exploitable state, eminently exploitable state, who has to come to
another human being who declares that he or she has knowledge to help
them, invites trust, pleased, obviously --- whenever you\'re cornered,
we\'re all pleased --- to have Jordan come and put those words down.

But I mean those words. And all of those are charged with moral
obligation. And what I would argue is that the obligations to the
profession are entailed, if I can use the philosophical sense of that,
entailed by the reality. So I\'m seeking for the internal morality of
medicine. Not that which is attributed to it, but entailed by the
actions we take, by the way we live at the bedside.

Just one final comment. Don\'t jump to the conclusion that that means
that I am ignorant of the social responsibilities. But I do think there
is an order of priorities.

When I\'m locked to you in that covenant of trust, when I said, \"Can I
help you?\" that\'s a covenant. It\'s something more than a contract. It
can never be a contract. How can there be a contract --- I\'m saying
this to the lawyers --- between two people who aren\'t equal? Not
unequal as human beings, obviously, but in their existential state.

When you\'re lying on the gurney, that\'s a different situation in which
to be. It cannot be a contract. You say, \"I want a contract.\" Well,
what do you want a contract for? You want to be helped, that\'s what you
want. I have promised to do it, having engaged trust, fidelity of trust
--- I won\'t go into all of it.

That\'s why I talk about the virtues, the moral agency they talk about
in general terms. It has to be spelled out, spelled out in intellectual
and moral virtues. Well, I don\'t mean to lecture you. I\'m just
pointing out the thoughts that were running through my mind as I heard
the discussion.

I\'m being perhaps a little critical, but I think what they\'re doing is
very important. But it\'s not going to catch unless it\'s got a moral
force, a moral impetus behind this, because we\'re in a moral
relationship. And that\'s not the only one, and not limited to medicine.
But it happens to be very acute in medicine. Think of yourself on that
gurney, and then you begin to understand what I think about medicine and
what we\'re committed to.

Ben, that\'s where I heard you say, \"It\'s not my patient.\" That\'s
right. That doesn\'t exist today, where you change at 5:00 o\'clock and
somebody else comes on. We know that has to change a little bit. But
nonetheless, when I see someone, you are my patient and I am your
doctor. Why? Because there is a certain covenant between us that can\'t
be eradicated. You\'ve entered into it. I can\'t wipe it out at 5:00
o\'clock.

Well, let me stop. I don\'t mean to make a passionate plea for a
profession which is having its problems today. It\'s having a crisis. I
really hope that that crisis, and I believe that crisis, will emerge in
another state of reformation. What it will be, I don\'t know. But I
think it\'s going to be crucial for all of society.

Which leads me to a point that I do think it should be a matter of
concern for this Council, because we are moving quickly from these moral
questions unresolved to resolution in legislation and in policy. That\'s
not the best way to do it. But let me stop.

Yes, Leon.

DR. KASS: The first thing to say is thank you, for that very articulate
and moving account, and also for the paper which we were given to read
which represents, for any of you who know, Ed\'s work over the years.
It\'s just a distillate, a wonderfully rich account of the medical
profession, beginning phenomenologically, what it is to be sick and what
it means to offer the helping hand.

And I have to say, I don\'t dispute the importance of the other things
that we\'ve been discussing, either at the last meeting or the earlier
sessions of this meeting.

But this does seem also to me an irreducible starting point for thinking
about, not professionalism, but thinking about the medical profession
and how it is healthy and rightly practiced. It seems to me right to
begin phenomenologically with the relation of the sick and the healer
who offers the healing hand.

It seems to be right to emphasize, at least to focus on the question of
what is the good to be sought. And you and I might differ about how many
of those four levels of good operate and in which way, but that\'s a
family quarrel.

To put the teleological question, what are you trying to accomplish
here? What is the goal? And therefore, in relation to that, what are
the, not only what are the intellectual skills that are needed, but what
kinds of traits of character and what kinds of powers of discernment and
judgment --- you call it \"prudence,\" I think, rightly --- are required
to fulfill the implicit, and maybe even explicit, covenant that once
upon a time taking the Oath might have meant publicly, and which is
tacitly present in each doctor-patient encounter, even though no one has
to say, \"I hereby profess medicine, and all of those things that go
with it.\"

I think this is the first paper that\'s seemed to me to put the center
where the center belongs. And I guess --- I mean, I\'ve got a lot of
questions, but maybe this would be useful: to invite some connection
between these central matters and the kinds of things about which all of
our other presenters have been speaking, where they seem to talk about
the external constraints, and some of them not only external, but
certain kinds of things having to do with the growth of medical
knowledge and specialization, things of that sort, how one would begin
to think about the preservation of this profound understanding of what
it means to be in the healing professions in relation to these kinds of
constraints that make this difficult.

You say that certain kinds of virtues are entailed. Well, they don\'t
automatically follow, if by \"entailed\" it doesn\'t mean that if you
have the covenant, you necessarily get the virtues. It means if you want
to fulfill this covenant, you will need them.

And the question is, how in the present age, under these circumstances,
should we begin to think about making this view of the profession vivid
to the rising physicians, this view of medicine vivid to them in the
face of all kinds of other things that suggest, and not wrongly, that
there are systematic constraints, there are systematic deformations,
there is the question of access, there is the question of distribution,
there is the question of specialization, there are the deformations that
the reimbursement scheme produces, of how much time you can spend
finding out what\'s going on.

So, for those of us who like this, how do we begin to talk about this in
relation to those things which are the most common and loudest
complaints? If I understand you --- and I\'m sorry to go on so long, but
I think this is really very important --- you seem to be saying that
there seems to be an insufficiently clear understanding within the
profession itself, or insufficient articulation of what\'s tacit to the
profession itself, of this kind of central core. And that if you wanted
to begin a kind of reform or rejuvenation, you would begin with focusing
on this.

These other people are saying, \"That\'s not the problem. The problem is
this can\'t go on except with that.\" And I guess I would invite you to
try to connect this to the other conversations that we\'ve heard.

CHAIRMAN PELLEGRINO: Thank you very much, Leon. As you know, coming from
you, I particularly appreciate that. I do think this is --- the problem
is that we don\'t have clinical teachers anymore who really believe that
the heart of the matter is at the bedside, and is with the sick patient.

Now, those who are not sick always say, \"Well, you\'re always worried
about sick people.\" But I go back to Hippocrates, the first line of his
treatise on medicine, which says, \"Medicine exists because people
become ill.\" Simplistic statement. That\'s why we\'re here. We have
public health positions. We have a responsibility to be involved with
the larger prospect of what we do, in catastrophe and war and so on, we
place the common good first.

But there\'s something, I\'ll use the word, \"sacred\" about my
committing to you in that situation of dependence that you find yourself
on the gurney. I don\'t know how to communicate that except to say it. I
can teach it, at the bedside, because this happens with every encounter.
You don\'t have to wait to have something designed.

Every encounter, whether it\'s very serious or not, I can tell you this,
as a physician for a long period of time, that there is no serious
illness that doesn\'t present a spiritual crisis to the patient.
Spiritual not in the sense of religious, but a confrontation with one\'s
own finitude, and that\'s the extreme of the vulnerability that a sick
person can go through.

So I don\'t know what to say, Leon, except that happily, when I talk
about this, just to raise you, give you a little more optimism, when I
talk about this, at least 25 percent of the audience will come and say,
\"We\'re so glad you said it. Somebody needs to say it, to reinforce
this. This is what we really want to do, but we can\'t do it.\"

And that goes back to the question of whether in fact the
instrumentalities and organizations of society --- we cannot escape
moral accountability, is the other part of that relationship. You\'ve
made a promise; you\'re responsible, now, obviously, in varying degrees
of mitigation of guilt. But that\'s not the same as being responsible
for an effect on the patient which is deleterious or a violation.
That\'s all I can say. Forgive me for the heartfelt presentation.

PROF. LAWLER: Well, sir, we have every reason to be proud of our Council
members, because compared to our --- I thought our speakers, although
very eloquent and passionate, spoke too abstractly about psychological
and moral distinctions.

And I\'m not making this up, because almost everyone on that side of the
table, on that side of the room, complained --- Carl, the most at
length, but also Gil and Diana. Whereas, your presentation, by contrast,
was so rich and concrete, because you\'re using the full array of moral
and intellectual virtues of Aristotle. This is a good thing. I\'m all
for this.

Nonetheless, someone might say, is it the job of the United States
government to reconstruct or an advisory body of the United States
government to reconstruct the ethics of the physician along Aristotle\'s
moral and intellectual virtues?

Now, arguably, we might have snuck that stuff in in previous reports.
But to do that straight out might raise some eyebrows. Because there\'s
a reason why these fine men and women speak so abstractly. That\'s the
way ethics is nowadays. That\'s the way ethics will tend to be in a
rights-based society.

So this would be a genuinely radical challenge, not only to your
profession but to all professions, in the way we think about ethics
generally. And that would require that we all raise ourselves to your
level of ethical expertise and detailed knowledge of Aristotle. So, I\'m
up for it, but it would be tough.

CHAIRMAN PELLEGRINO: Thank you, Peter.

DR. FOSTER: Can I follow up with that, and Leon\'s statement? I mean,
let\'s say you think that professionalism is something that should be
continued by the Council and some sort of a report brought from it. But
one of the things that Leon mentioned was connections, and you just did
the same thing, Peter, and so forth.

I mean, if you follow up on Peter\'s statement that if this is an
advisory Council on the greatest bioethical, politically bioethical,
questions facing the country and the Council is not fundamentally
related to physician failure and professionalism and so forth, but has
to do with the issue of a system that does not take care of its people
--- and two or three people have said this today. I mean, you\'re not
going to have an answer to the delivery of healthcare and the coverage
system.

But it seems to me that one way you could, if you didn\'t want to just
come out and say that we don\'t have a solution to the problem, but we
believe that the number one --- and everybody in the presidential thing
is talking about it --- but that we think that this problem needs to be
dealt with.

And one of the ways you could conceivably venture into that is to say
that it\'s even having a huge problem on the professionalism issue of
the physician, even there. Now, that\'s sort of a fake way to go at it.

But I still am worried about the fact of every --- I don\'t know about
you all, but the question that I get most often is what is the Council
doing after the stem cell thing? I mean, for people who don\'t know what
we\'ve been doing. And they all say, \"Why don\'t you say something
about healthcare?\"

It seems to me that in the professional, at least in my medical school
and other places, that that\'s the question that I get most often. \"Are
you afraid to deal with this because it\'s political\" or whatever, and
I think that\'s a question that really ought to be addressed.

I mean, it would be of the seriousness that was involved with some of
the other things that the Council has done. I don\'t know. I mean, the
Chairman speaks exactly what I feel about medicine, and I think
everybody here feels about that, too.

But I think Peter\'s point is sort of an interesting one. You\'ve got
two more years to go on the Council, and so you say you\'ve spent eight
years and you\'ve never said one word about the issue of justice and
mercy in terms of medical care.

If you live in --- I\'m lucky enough to live in Dallas, where we have a
great hospital for the poor. The political community, both the
commissioners\' court, the counties, agreed to raise taxes. They want to
raise \$1.2 billion for a new Parkland Hospital to take care of the
poor.

I mean, that\'s a community that\'s --- 1.2 billion is a lot. And the
school district wants 1.2 billion for new schools. But I\'m a little
concerned, and maybe I\'m the only one who gets that question. I got a
lot of questions about our report on organs and so forth, about what are
you going to do? It\'s now up to 97,000 people waiting, you know.

But I just think we ought to really address the question, are we going
to avoid this? Now, the problem is that we don\'t have the expertise and
can\'t get the expertise. And there are people, economists and everybody
else who know far more about this.

I\'m just thinking about a moral pronouncement about an ethical problem,
a moral pronouncement, not a solution. But saying that the country ---
that we believe, as a body assigned to ethics, needs to address the
question.

And we know that it\'s in the political thing, but let\'s say whoever
comes in, it might be useful to --- maybe because this Council was
formed under President Bush, that anything we say, if it\'s a Democrat
that\'s elected, doesn\'t want to have anything to do with what we say.

But I do think it would be worthwhile to have a sentence or two before
we adjourn --- and I know it\'s late --- but whether we ought to look at
that.

CHAIRMAN PELLEGRINO: If I can abuse your patience for a minute or two
further on this issue. I also feel --- I\'ve been talking about the
individual physician. I also feel that the profession of medicine as a
community is a moral community. Now, a moral community is not a comment
on how they behave, but on their obligations.

And I think that while our first obligation is to the individual person
to whom we\'ve committed ourselves, is to that person, there are other
levels, three more levels, in the way I develop it. Because we took an
oath of committing ourselves to something beyond self interest when we
took that Hippocratic Oath. That was the real essence of it, from the
point of view I\'m talking about. We did it together. We\'re responsible
for what each other do.

We also in that have declared over and over again, in the preface to the
AMA\'s Code of Ethics, that we are interested in the public. Therefore,
the moral question comes up, what does a good profession or a good
society owe the sick, those on the margin?

I think it is a major question, and I think the two go together. And I
don\'t think we can consider ourselves moral professionals unless we are
involved in some way. And again, I don\'t want to take you down the
pathway of the things I\'ve written.

But I do feel that that\'s part of the same kind of commitment that I\'m
talking about. Excuse me, Gil.

PROF. MEILAENDER: I\'d just ask you to clarify something. Is your
question what your profession owes to the sick, or is your question what
the rest of us owe to the sick? Because, I mean, those are different
questions.

CHAIRMAN PELLEGRINO: Yes, yes.

PROF. MEILAENDER: And it seems to me that most of the time we start with
the question of what your profession owes to the sick and it turns into
a question of what the rest of us ought to make possible for your
profession to do.

And I think the rest of us do owe something to the sick, but I\'d like
to sort those questions out a little bit.

CHAIRMAN PELLEGRINO: You know, I take that distinction, but I think we
should be leading, because of our close relationship to the human being
in the existential state of illness.

I mean, that\'s what we\'re talking about when we talk about the
healthcare system. We\'re not talking about a system. We\'re talking
about a group of human beings who we know, and they\'re in that
vulnerable state and not having access to what we think, out of mercy,
or love, or whatever, we should be providing them.

I feel we have a moral obligation. A good society has a moral
obligation. Now, if this group wanted to go down that line, I would love
to go down that line and explore it further.

Yes, Gil?

PROF. MEILAENDER: If I may just push once more. I don\'t doubt that ---
I mean, I\'m not sure about this \"leading\" metaphor. You asked us to
put ourselves on the gurney.

CHAIRMAN PELLEGRINO: Yes.

PROF. MEILAENDER: Where we will all be someday, or someone else whom we
love deeply. So, the question of, sort of, who leads in this discussion,
whether the medical profession leads or whether we as citizens lead
seems to me to be a worthwhile one, also.

CHAIRMAN PELLEGRINO: Oh, I absolutely do, because I think that when I
speak to non-physicians or the general public on this, about the state
of the healthcare system, I\'ve said, \"You get the healthcare system
you want, and what you have is what you want in the United States until
you change your notion of what the moral obligation of this society, if
it\'s a good society, is to the sick, the poor, the on-the-margin.

Now, I sound like I may not even belong to this group, but that\'s my
view of the matter.

PROF. GEORGE: Dan, let me say what I think the problem is, and perhaps
you can respond.

There are moral positions that would dictate a policy, generally
speaking, if they were adopted. For example, someone who, as a moral
matter, believes in strict libertarianism, would want an entirely
privatized system in which there was minimal government involvement, and
would be prepared to tolerate any consequences, as far as the
inaccessibility of some people to healthcare services, because of that
moral commitment.

Another example would be strict socialism, where someone who just
believes in that as a moral matter would say, \"Look, we should have a
government-run healthcare delivery system because that\'s just the right
thing to do,\" and that would override competing considerations.

So, yeah, in those cases, if you happen to hold a view like that, then
the matter is sort of dictated before we get into the details of the
costs and benefits and tradeoffs and consequences of different
opportunities, opportunities falling outside the bounds of the
particular view.

But I suspect strongly that most people on the Council are like most
people in the country, most people in the Congress, neither strict
libertarians nor strict socialists. Rather, they are people who believe
in the dignity of each and every human being. They do not want to see
people suffering or deprived of healthcare when they are in need. But
they\'re not committed to a moral conception that will dictate either a
pure free-market system or a pure socialist system.

They would have that policy judgment be made on the basis of a whole lot
of factors that certainly are considered within a moral framework, that
includes a commitment to the dignity and profound worth of each
individual human being.

But where what\'s actually going to generate the conclusion would not be
moral considerations just as such. There would be economic
considerations, questions about what tradeoffs we ought to be willing to
make, efficiency, just lots of factors that would have to be deliberated
about, and about which reasonable people can disagree and about which,
at least in some cases, I think wouldn\'t be a single uniquely correct
answer.

They would be different people making different tradeoffs, or judging
different tradeoffs differently, which means I think that the most we
could say, unless we\'re prepared to go with a view that --- a moral
view, libertarianism or socialism or some other one that would dictate
the answer independent of considerations of efficiency and tradeoffs and
so forth. The most we could say is I think what you were calling a moral
pronouncement. But it would have to be a pretty general moral
pronouncement. And maybe this would be sufficient from your point of
view.

But it would have to be something as general, it seems to me, as \"We
believe and we know our country is committed to the proposition that
each individual human being has a profound dignity, that life and health
are intrinsic and great human goods and should be respected and advanced
in people and never directly harmed, that we therefore find it a very
bad thing indeed that there are many, many, many people, a high
percentage of people in the country, who do not have insurance to cover
the kinds of needs that they could very well and often do experience.
And this is an issue that\'s got to be dealt with.\"

Someone\'s got to. We have to do something about it, but we can\'t say,
because we haven\'t gotten into the non-moral considerations where we
don\'t have any particular expertise to say. No one can say whether it
should be basically a market system, basically a government system, or
some mix of the two; and if a mix of the two, at what level they are
mixed.

And that leaves me wondering whether such a statement could rise above
--- and I\'m open, so tell me if you think it can --- could rise above
the platitudinous.

See, I think when it comes to other issues, whether it\'s embryonic stem
cell research or certain sorts of operations that are not medically
indicated, Botox or what have you there, I think there are moral
considerations that would lead at least some people, large numbers of
people, to think we can resolve issues like that and have something
important to say on issues like that, or at least marginal to relevant
moral considerations before the public to resolve the issue.

But with the general problem of access to healthcare, I don\'t see it as
the same. Can it rise? Could we make a statement in your view, Dan, that
would rise above the platitudinous?

DR. FOSTER: I don\'t know. I don\'t know. It might just be a platitude.
I mean, I have no idea that it\'s a platitude. Well, we certainly can\'t
do the methodology, you know, you could have a basic health system for
the masses and a free system above --- you know, there are ways that you
could do it.

What we know is that essentially every developed country in the world
has made a decision that they\'re going to take care of the people who
are ill in the country. And we have, for a very long time, not had that
thing. It increased, according to the latest census, another 6 million
people who are uninsured. So I recognize that it might be a platitude.

But some very smart people, people like Seldon and people who have
thought about this, and so forth, say that they think that it might be
an enhancing thing for the Bioethics Council to say \"This is a crucial
problem to solve, and that we as a society need to do that.\" And it may
just go off into the air. I have no idea.

I do think, and I don\'t have any statistical thing, I\'m just telling
you what people talk to me in the hall about, \"Why have we not had a
word about this critical thing?\" And I think it might be worthwhile for
us to say, if nothing more, that this is a crucial thing that needs to
be dealt with. I mean, we\'ve talked about enhancement, we\'ve talked
about all sorts of things that the bulk of the country are not. You
know, it\'s an intellectual problem and it\'s an ethical problem.

So I don\'t know, Robbie. I think you\'re, as usual, right on the mark.
And I don\'t know. I just --- because I just felt like after we\'ve been
talking, spending all this time on professionalism and so forth and so
on, and it\'s impacted by these things, as Leon just said, and Ed said.
I don\'t know.

We\'d have to decide whether that\'s --- the Chairman has said he
thought it might --- I think I heard him say he thought if we went down
that road he would be enthusiastic about it. And just the fact that we
--- I don\'t know. It might just be steam. I don\'t know.

CHAIRMAN PELLEGRINO: I have Carl, Rebecca and Bill. And I just want to
respond quickly, Robbie. I fully agree, though on the methods of getting
there and the intricacies of the system, there are going to be people of
good will differing enormously. But I think if somebody could come out
and say, whatever we do, it\'s got to be driven from ethics. The ethics
drives the system and the economics, rather than the economics drives
the ethics, that would be a tremendous advance. And I think that is
appropriate for a group like this.

Now, let\'s hear Rebecca, Alfonso and Carl. And also, we\'re under the
threat of having to evacuate this room at 5:30. (Bell sounds.) Wow. But
if you can do it quickly, go. In that order --- Rebecca, Alfonso and ---

PROF. DRESSER: Well, I\'ve got the same question that Dan gets quite a
bit. And I\'ve been asking that question for quite a while, and I know
quite a few other people on the Council have. Why aren\'t we doing
something on this issue?

I do think we\'ve tried to say some things about it in the \"Taking
Care\" report. But I would --- as someone who was recently on the
gurney, I have trouble saying it because of the reason why I was.
Really, the description that you gave is so powerful. And I think it
doesn\'t necessarily require highfalutin Aristotelian stuff, although
that would enrich it, but it really would resonate with many, many
people on a personal level and would take us down to the ethical, moral
heart of the matter.

And then moving upward, it would be possible to connect certain problems
that have been discussed, such as, some people, when they\'re in this
very vulnerable position, all they can do is go to the emergency room
and wait around in the corridor and suffer. And this is an ethical
problem.

Now, we don\'t have to say, \"And here are the nuts and bolts ways to
fix it.\" That\'s what everyone else is talking about. But if we could
boil it down to a core presentation of the harm that this does, I think
that that could be powerful and useful.

PROF. GÓMEZ-LOBO: Repeating a little bit, I would ask Robbie, what\'s
wrong if it is a platitude? I mean, it is true that we cannot go into
specific solutions, but platitudes are self-evident truth, all men are
created equal, stuff like that, and need to be said precisely because
they have not sunken in. I\'m amazed, for instance, when I talk with
Europeans or with Latin Americans. They are simply amazed that Americans
accept the fact that there are now --- what is it? 47 million people
without health insurance?

DR. FOSTER: The figure I remember is 46, but ---

PROF. GÓMEZ-LOBO: Well, they said that it increased by 6 million. So I
see a value in making this statement on the part of the Council, even if
it is platitudinous. Simply for the reason that if it sinks in in the
American public, if it reaches the Congress, you know, as a kind of
moral pressure on them to seek a solution, or the next president, I see
it as an important thing, even though it may be a platitude.

PROF. SCHNEIDER: I certainly agree that it would be silly to spend time
trying to think about what the right kind of system would be, if only
because I think the right kind of system is whatever system could be
politically possible. Almost any system that achieves the end is going
to be better than giving up on it altogether.

It may be a platitude, but it\'s a platitude that gets lost track of a
lot. It gets lost track of by bioethicists, who rarely interest
themselves in it. And it\'s a platitude that gets lost track of when we
have discussions about how to reform the healthcare system, because
those tend to wind up being discussions about how this is going to
affect my ability to work with my doctor, and so on.

So I think it is at the very least a platitude worth repeating and a
platitude that\'s actually true.

DR. KASS: I have, I guess, mixed thoughts about this. The importance of
the issue is, I think, evident to everybody in the room. The question
is, what would the useful contributions from a Council like this be?
When some of the bioethicists who are interest in this subject actually
start to speak about it, they think that the grounds of the
justification for doing something are self-evident.

We\'ve heard \"social justice\" repeated many times. It must have been
Peter, I guess, who raised some question as to whether people who use
this as a shibboleth have thought five minutes about the very meaning of
it. Because they seem to use it as a slogan as if it\'s sort of
self-evident. And it seems to mean something like equality.

But it does seem to me it might be a useful thing to articulate the
ground of doing something about this, not just the outrage that there
are people who don\'t have care. But it\'s one thing if you go at this
in terms of people have a right to something and therefore others have a
correlative duty; it\'s another thing to say that healthcare is a social
good and therefore it\'s a matter of distributing the social good, and
it\'s a problem with distributive justice.

Neither, by the way, not that it matters, would be my preferred way into
this thing. It\'s another thing to ask the question of how should a good
society think about the needs of its least fortunate members, and do
something not only for them but in a way for all of us?

And it does seem to me this isn\'t going to solve the problem. But there
would be a way of articulating the different kinds of justification, and
even to argue for the better ones, what we think might be better ones.
That might be a contribution and a way of highlighting this subject, and
not merely screaming about the outrage and quoting the numbers.

Or --- and here I would underscore what Gil said --- it\'s one thing for
doctors to say, \"We can\'t practice medicine the way we would like to
practice\" when --- and this was 45 years ago, at the University of
Chicago Hospitals, if the guy didn\'t have insurance in the emergency
room, you hung up an intravenous and sent him to Cooke County. And that
was a terrible thing for a young medical student to see. That\'s one way
to answer the question.

The other thing is the question, if you really start from the good
society and ask what it owes, you\'d have to then think about what it
owes in education, you\'d have to think about what it owes in terms of
public safety and various other sorts of things. And then the question
becomes much more complicated.

So I do think there\'s something to be done here, if we\'re willing
really to treat this as a question rather than as a slogan. And I think
it would be very important, because the sloganeering only gets people\'s
backs up.

And if we put some serious thought into this and try to articulate a
principal defense for doing something, and a good diagnosis which does
more than say, \"There are these many uninsured,\" without breaking it
down, and things of that sort, then I think there\'s a real benefit
here.

CHAIRMAN PELLEGRINO: And that will have to be the last comment, because
we are in violation of contract for all the time we go over 5:30.

PROF. GEORGE: At least it\'s not a covenant.

CHAIRMAN PELLEGRINO: Bill?

DR. HURLBUT: I just have a few reflections. I think maybe it\'s good to
get them out, since this is the context of our larger effort. It\'s not
a direct sequence to what was said here about the social/political
dimensions.

But reading your essay and reflecting on what Leon said about the
personalism of your articulation of the notion of declaration of
professionalism and its personal covenant and how they might connect
with the broader social engagement and social responsibility, it strikes
me that there are a few things worth saying. These may sound a little
abstract, but I think there are tangible ways we could articulate them.

One thing that --- and I don\'t know quite how to even say this. But I
feel as if, as a physician trained in what I consider to be a very
privileged kind of encounter with humanity, seeing people on the gurney
is like nothing else. I think because of certain social factors, we\'ve
become overly self conscious and somewhat dishonestly humble about what
we --- who we aren\'t.

And I think there\'s a sense in which we might be able to say something
about what we are, or at least what we ought to be, given the privileged
encounter that we have in medicine. And so in an idealized way I\'d like
to put out just a few things about that, quickly, and we can come back
to them some other session.

It seems to me that as a physician, we have a very unique appreciation
of the psychophysical unity of the human person, that we understand that
what a person is is to a certain extent a product of forces that they
didn\'t choose, that they inherited genetically or circumstantially. And
that\'s a very strong root of compassion that I think only a person
trained in biology can really plumb.

Second, I think we see the fragile balance that the psychophysical unity
means, that there is a danger of its disruption, and therefore, we have
to be very careful what we use the new powers, especially as we gain
powers through biomedical technology, what we as a profession use our
powers for. That there is a connection between our biochemistry and our
personal and spiritual existence that we should not disrupt.

Third, I think that we have a privileged encounter with what you
articulated, the frailty and finitude of life, and that therefore, a
sense that life isn\'t always about what you might think it\'s about if
you\'re just watching television. That life is a very serious journey,
and that sooner or later, whether we want to face it or not, we will see
it from the horizontal as a serious matter.

And this gives us a particular relationship with the reality of
suffering, and a role that I\'m very aware of. My wife is a
pediatrician, and she comes home some days and is very drained, and
needs a little kind of lifting up, and she\'s very strong. But it keeps
reminding me of what I know from my own experience as a physician, that
we do more than just diagnose and treat; we also absorb.

We absorb an awful lot of fear, we absorb frustration, disappointment in
people\'s lives, and even anger, and that this is an intrinsically self
--- not just self-effacing, but self-draining, in a way. Something ---
it takes a lot out of you to encounter this. And yet it\'s a very great
giving. There\'s an implicit kind of sacrificial relationship that\'s
involved in this profession.

And finally, I think that --- I don\'t know how to even articulate this.
But it\'s very plain to me that medicine as a profession is a profession
because it has a limited prerogative. It isn\'t about everything. We are
not going to properly ever relate to our larger social engagement
properly, in my opinion, as engineers, nor are we ever going to really
be a substitute for priests and their equivalent in various languages.

And finally, it struck me as one of our speakers was speaking about the
White Coat Ceremony --- it struck me that --- you used the word
\"sacred,\" I believe, earlier today. It struck me that it\'s very
interesting this is a white coat; it\'s not plaid, it\'s not striped,
it\'s not paisley. There\'s something about the white coat. There\'s a
kind of a purity --- is that the right word? There\'s a kind of trueness
in it, a nobility, a dedication, and a mercy to go along with being a
physician.

There is an effacement of self-interest, as you said. But you made an
interesting statement in your paper. You said, \"This is not to demand
absolute or heroic activism more than is expected of nonprofessionals.\"
And yet, there is a special role here, and that strikes me as modeling a
dimension of reality that isn\'t plain to the average person.

So whether we\'re more dedicated and more sacrificial, no, that\'s not
the point. The point is that ours is a very special role, that we model
in this arena where these kinds of issues are so vivid and evident,
deeply personal, deeply vulnerable.

And this unequal relationship does give us a special, a privileged
understanding that we don\'t need to apologize for, but that we need to
live up to. It makes failure more troubling, obviously, when it\'s
unethically conducted, but it also makes a competent and compassionate
profession all the more powerful.

CHAIRMAN PELLEGRINO: Thank you very much. Well, thank you all for your
comments, and I appreciate it very, very much, and allowing me those few
moments, those few quick remarks. Thank you.

(*Whereupon, the proceedings in the foregoing matter went off the record
at 5:48 p.m. to resume the following day, September 7, 2007 at 8:30
a.m.)*