February 2, 2006
COUNCIL MEMBERS PRESENT
Edmund Pellegrino, M.D., Chairman
Benjamin S. Carson, Sr., M.D.
Johns Hopkins Medical Institutions
Rebecca S. Dresser, J.D.
Washington University School of Law
Daniel W. Foster, M.D.
University of Texas, Southwestern Medical School
Michael S. Gazzaniga, Ph.D.
University of California, Santa Barbara
P. George, D.Phil., J.D.
William B. Hurlbut, M.D.
Leon R. Kass, M.D., Ph.D.,
American Enterprise Institute
Peter A. Lawler, Ph.D.
Johns Hopkins University School of Medicine
Gilbert C. Meilaender,
Janet D. Rowley, M.D., D.Sc.
The University of Chicago
Diana J. Schaub, Ph.D.
CHAIRMAN PELLEGRINO: Good morning. Welcome. Let the record
show that Dr. Daniel Davis, the Executive Director of the
President's Council on Bioethics, is present as the Official
I also want to welcome Dan who was appointed recently to
the directorship and he is my boss now, officially.
As tractable as I ought to be, he'll have trouble, no doubt,
ordering me around, but Dan, we're happy to have you. Dan,
you have his curriculum vitae. He's come to us from Georgetown
with extensive administrative experience, not only in academia,
but in government and otherwise. He has his doctorate degree in
philosophy, and his concentration is in philosophy of medicine.
Dan, thank you for joining us.
DR. DAVIS: Thank you.
SESSION 1: THE CONCEPT OF HUMAN DIGNITY
CHAIRMAN PELLEGRINO: The first session this morning is a
continuation of our discussion on the question of dignity. As you
know, we've been looking at it. The Council has used the term in a
number of its publications, explicitly and implicitly, and we thought
it well to examine the spectrum of meanings from wide points of view.
This morning we have two points of view presented.
We'll start first with the representation our first speaker will
give us, from the point of view of philosophy and philosophy of
neurobiology, looking at the question of human dignity.
You have the curricula of all the speakers and I'm not going
to vex them or put them through the déja-vu phenomenon, hearing
themselves described again and asking who is it that they're
talking about. So if you make reference to the text, I think you'll
have it straight and in no way filtered through my aging cerebrum.
So we'll start, immediately, Dr. Churchland. The floor
is yours. We'll follow the usual procedure. Following Dr.
Churchland's presentation, we'll have an open discussion by the
Council Members and we'll begin immediately to try to keep
ourselves on schedule.
DR. CHURCHLAND: Thank you so much and thank you so much
for inviting me to be here. It's a great privilege to be here and
I come with good wishes from my colleagues in California.
I looked over the working paper prepared by Adam Schulman
and this was after I had accepted your invitation and I was really
quite daunted, because it's such a wonderful document that I felt I
really might not have much to add.
So I spent a certain amount of time thinking how I could be
most useful to the Committee. And my view was that it might be better,
rather than to — let's see now, all right, how do we do this?
There you are.
Rather than to focus on a discussion of the concept of
dignity, to just sort of remind ourselves, I think what we all know is
that categories including categories about ethics and politics, as well
as categories about the natural world, are learned from examples. They
have a radial structure by which I mean there are sort of central
exemplars and then further out from the central exemplars are cases
where some people think they fall in the categories. Some people think
that they don't. And there may not be agreement.
The other thing about categories that we all know is that
they change over time. When I looked in the OED as to what Chaucer
thought dignity meant, it's really a little bit different, I think,
from what Shakespeare meant later on and probably also what we mean
Schulman noticed this, of course, in his discussion of
dignity and so he asked the question what is essential to human
dignity. And I thought perhaps it might be most useful to the
Committee if I approached this in a slightly indirect way. And the
perspective that I'm going to take will be the perspective of
biology or more specifically neurobiology.
And the first point that I want to make has also been made
by many other people, including Mike Gazzaniga, who is here, which is
that moral dispositions are part of our human nature. Second, I'm
going to make several historical points on medical technologies. And
finally, I'm going to draw a connection between Aquinas and modern
Moral dispositions are part of who we are. It appears from everything
we know from both neurobiology, but certainly evolutionary biology
and ethology that we social groups have been selected for, that
individuals who had social traits such that they could cooperate,
share food, share in defense and so forth, did very well. And consequently,
the disposition, via the genes, is in many social animals to behave
well towards one another, care for one another, and whatever is
necessary in order for traits to propagate through or spread through
And certainly one is that people have to — or animals have
to be able to identify one another. They have to be able to cooperate
and to compromise. They also have to be able to detect cheating and to
be willing to punish the cheaters.
We know, of course, that there is an interaction between
genes and culture and between culture and learning, that the genes do
not wire up the brain for specific standards of behavior, but that
standards of behavior are typically learned by the young in the social
We also know now that learning involves changes in gene
expression, and that certain properties have to be in place in the
neonate in order for social dispositions to flourish, for example,
it's now known, although this is not surprising, that levels of
oxytocin vary as a function of infant fondling and that levels of
oxytocin and consequently levels of — or population density of
oxytocin receptors are extremely important for social cognition,
generally, and for social behavior, in particular.
So that's just the very general kind of background that
I want to give you about the neurobiology or more generally, the
biology of social behavior. It's the particular standards that
vary from culture to culture and indeed vary within a culture over time
that I now want to turn to.
There have been profound changes in moral beliefs about
certain kinds of practices. At various points in our own culture,
public executions were common as was child labor, slave labor, genital
mutilation and lack of female suffrage. This, of course, has changed,
and I just use this to remind us that, in fact, child labor was very
And I want now to specifically address, not just changes in
attitudes toward certain institutions, but also I want to look a little
bit more closely at changes in attitudes toward specific medical
technologies. Now what I'm going to say hereafter really does
require quite a lot of commentary and I was a little bit reluctant to
send out the slides in their naked form because I can't provide the
commentary unless I'm actually here.
So I want to provide some commentary, but I also want to
invite commentary on this and Ed Pellegrino has already been very
helpful in making some observations to me.
All right, a very general background point, and it looks
like the following, that when humans are ignorant of the causes and the
mechanisms of a particular phenomenon they can't control it,
whether it's the weather or certain kinds of diseases or what have
you. And when we are ignorant and we cannot control it, we tend to
acquiesce and we see the gods or God as the thing that is in control of
As we acquire knowledge, we often acquire control and
it's not uncommon and it's quite understandable that through
this transition, we tend to see technology as usurping the proper role
of God. And this was, for example, true with regard to anesthesia.
Many people felt that the experience of pain, especially in childbirth,
was entirely appropriate and that it would be usurping God's proper
role to intervene in amelioration of pain in childbirth.
But when the benefits of a particular technology become well understood,
when those benefits are seen to be dramatic and to overwhelm the
particular objections of tradition, then we tend to see a moral
reversal. Not just a wholesale reversal, but what typically happens,
and of course, we've seen this in our own time with genetic
engineering, limits are negotiated. We say that the technology
has a particular sphere within which it can operate and then we
put limits and regulations on the development of that technology.
And that's, of course, very true of anesthesia. You can't
just haul off and anesthetize people or yourself willy-nilly. It
has to be very highly regulated and highly controlled.
So I want to remind you that there has been opposition and
reservation on the part of various religious groups throughout history
with regard to medical technologies. At the same time, and this I
couldn't actually put in the slides, it's very important to
understand that there have been just the same, many religious groups
who have been wholly supportive. And so often, the controversy has
really been within religions as opposed to a controversy between
religion and the secular world.
In the 18th century, once smallpox vaccination was discovered,
it was bitterly opposed by various sects, although so far as I could
tell, not officially, for about 30 years. Actually, it extended
much beyond that, well into the late 19th century in Montreal in
Canada. French theologians in the Sorbonne objected, English theologians
objected and I just mentioned two papers that were really quite
influential. And there really was very little religious basis for
the objection to smallpox, but roughly speaking, people referred
to those who did oppose, referred to the text where it is said "He
hath torn and he will heal" which of course, is very open-ended
and ambiguous after all.
But the relief from smallpox via vaccinations was, of
course, extraordinary. At one point there were roughly 1 in 13
children who died every year of smallpox. Within a period of about 20
years, that completely changed, and as we know within our own time,
it's extraordinarily rare to meet anyone who has ever known anyone
with smallpox or even very few of us who have had a smallpox
vaccination, although I bet you have and I certainly did too.
And now we still see reservations about other kinds of
vaccines. For example, the Focus On The Family organization is
concerned about the vaccine for cervical cancer which we have reason to
believe is about 100 percent effective. The opposition seems to derive
mainly from concern about premarital sex and especially about sex
amongst unmarried adolescents.
I'm not putting this here to say that this is an inappropriate
concern, but only that we do still have, based on religious concerns,
opposition to certain kinds of vaccines.
Now the issue of dissection is slightly more controversial than
the slides would suggest. There was certainly opposition to the
notion of dissection of cadavers. I think Ed Pellegrino can probably
give you a more detailed account of this reservation than I can,
but certainly there were people in the Renaissance, for example,
Leonardo, who was — who had dissected bodies and who was scorned
or condemned for having dissected bodies, dead bodies.
Now I want to turn to the issue of anesthesia. Various
kinds of anesthetics have been used for a long time, including
especially I think alcohol. But of course, it was in the 18th and 19th
centuries that the really important discoveries were made regarding
ether and chloroform and then, of course, later in the 20th century.
The main issue about the use of anesthesia concerned childbirth.
The argument was, and again this is from only some religious orders
and opposed by others, the argument was that in Genesis 3:16 it
is said to the woman — this, of course, is after the expulsion
from the Garden of Eden — to the woman God said, "I will
greatly multiply your pain in childbearing, in pain shall you bring
And the painting that you see here is actually a medieval
painting of a woman undergoing a Caesarian section without any sort of
anesthesia, typically, of course, they died.
In America, William Thomas Green Morton pioneered the
surgical use of ether in 1846 and in Scotland, it was James Young
Simpson who discovered the use of chloroform.
There's quite a lot of documentation regarding
opposition in England and in Scotland to the use of anesthesia and
there was a lot of debate about it. And interestingly, still some of
Simpson's letters are extant and we can see something of the nature
of the debate from his letters. So I give to you just one very small
quote from a clergyman in Scotland who wrote to Simpson arguing
"that chloroform is a decoy of Satan. It appears to be a
blessing, but it will harden society and rob God of the deepest cries
Simpson tried to respond to these arguments, but of course, eventually
the use of chloroform and ether in childbirth was deemed to be such
a blessing and such a boon that these sorts of arguments really
just kind of faded away. And I think it's hard for many people
to realize how deep in spirit the opposition to anesthesia was during
Pope Pius XII, 1956, condemns transplants from living
donors and Ed Pellegrino informs me that this was only if the life of
the person was put in danger. In other words, it was a very reasonable
opposition to the idea that one might sell one's own body in order
to provide organs for someone else. Nevertheless, this was interpreted
by many, both within and outside of the Catholic Church as a
condemnation of the use of organ transplants at all and especially the
use of organ transplants from living donors.
And what's so interesting about all of these cases is
how our attitudes really shifted. And it almost shifted imperceptibly
so that now it is considered a tremendous benefit if a twin provides a
kidney to another twin.
And so now we turn to the issue of blastocysts and the use of
embryos in stem cell research with the possibility, a possibility
of great benefits to humans. And I'm going to back up a little
bit here and address what I think many of the scientists indicated
they did not want to address and that is, is the conceptus or the
blastocyst a person? Now in his book, The Ethical Brain,
Mike Gazzaniga makes a number of very useful points, but one of
the very useful points is on this particular issue. He points out
that continuities are typical in biology and that very often we
can, nonetheless, distinguish endpoints of a continuum, especially
in those instances where we need some kinds of rules or standards.
Plato actually made the same point. He said that there is
something called the fallacy of the beard. And the fallacy goes like
this. One might argue that there is no sharp distinction between the
clean shaven man and the man with the full bushy beard because at every
point there is the tiniest increment of length of hair. And if one
were to argue then that there's no difference between the clean
shaven and the bearded man, argued Plato, that would be wrong. It
would make no sense and consequently, we should be able, even if we
can't make precise distinctions, we should be able to make rough
distinctions that make sense.
And in his book, Gazzaniga essentially argues the same
thing. The blastocyst may have the potential to be a person, but is
not yet, in fact, a person and we should be able to distinguish between
a conceptus and a fully formed human that is born at term.
We may not be able to draw precise distinction as to
exactly where it becomes a human, but we can draw a rough and useful
distinction and I'm going to come back to that point in a moment.
And just to add my own point here, I think we need to be
terribly careful about the idea that if something is a potential X,
then we need to treat it as an X. I am a potential cadaver. I am
potential fertilizer, but I would not want you to treat me as a cadaver
or as fertilizer.
And the point I really want to make now draws on Aquinas. Aquinas,
arguably the greatest Catholic theologian of all time, had a very
interesting view about human nature and he addressed very specifically
because he was tremendously interested in the biology of all of
this, about when the rational soul, meaning the soul that is capable
of true mental thought, when the rational soul enters the fetus.
And this was in his famous tract, Summa Contra Gentiles.
Now what he thought was that there are essentially a
variety of stages and that at the very earliest stage what he would
call the conceptus, which he really just thought of as the sperm now in
a nice environment because he didn't really know that the egg
contributed anything, partly because they didn't know there were
eggs. That early on the conceptus has a vegetative or nutritive soul
meaning that it can grow and that it can develop. Later, it has a
sensory soul, meaning that it can respond to sensory information. And
significantly later, it has the capacity for thought. And he thought
each of these stages had to be tied to the appropriate bodily organs
that were in place at that time.
And part of the reasoning behind this was he wanted to, as
Aristotle did, to be able to explain why it is that rocks and streams
and trees do not have rational souls. And the argument is really very
interesting and very modern. The argument is they do not have the
appropriate organs. And they both realized that for rational soul the
appropriate organ was the brain.
And so I'm just going to put in this quote which I added on
the plane yesterday just to indicate to you how really advanced
in his thinking Aquinas was: "The vegetative soul which is
present first when the embryo lives the life of a plant is corrupted
so that it has its time and then a more perfect soul follows which
is at once both nutritive and sensory and then the embryo lives
the life of an animal." (It's not yet a person.) "With
its corruption, the rational soul follows infused from without.
Now we may not think the rational soul is infused from without or we
may, it doesn't really matter to the argument. In any case,
it was his view that males at 40 days had a rational soul and that
females at 90 days had a rational soul. I'm not sure why the
difference, but in a certain sense, that's an empirical question
and what he would have said is that's a purely empirical question
and on which he would be happy to be wrong.
And as I said with regard to the current controversy about
stem cells, I actually feel very optimistic, optimistic because of the
history of medical technologies and the changes in attitudes that we
have seen historically toward medical technologies. And in concluding
then I want to just say a little bit about how maybe we can move from
the controversies themselves to negotiating various kinds of
regulations, agreements about how to do it so that although we might
all need to compromise a little bit, we can move forward.
Colin Blakemore is the head of the Medical Research Council in
the United Kingdom and he is the head of United Kingdom regulation
of stem cell research. In 2001, the House of Commons prepared legislation
that allowed human fertilization and embryology for research purposes
to go on, but they introduced regulations. And amongst other things,
the regulations prohibit reproductive cloning, but it allows for
new knowledge and applications.
The House of Lords, the second house, provided bills for a
stem cell bank which set down very strict codes of conduct under the
regulation of a steering committee. So very roughly this is how this
looks. So there's a stem cell steering committee and these groups
are all independent of one another. And this is extremely important, I
think, in order for the researchers and the donors, for example, to be
So in the United Kingdom, the stem cell bank roughly works
as follows. There are separate facilities for research grade and
clinical grade stem cell lines. The banks and the supplies are
ethically sourced. They are quality controlled adult, fetal and
embryonic stem cell lines. They will be accessible to people in the
Academy and in industry and overseas, but only with proper license and
accreditation and all of this is dependent on the approval of a
completely independent steering committee in order for you to have
Now I am not sure that this is exactly the pattern that we might
want to follow. I think it will be important for us to see where
the strengths are in the U.K. regulatory system, where the weaknesses
are, to develop our own regulations that suit us and our particular
needs and our particular constituencies. But I do have —
and this is why I'm optimistic — I do have the feeling
that, as an understanding of the benefits increases, and as an understanding
of what the conceptus really is and what a five-day-old embryo really
is, that attitudes will change. We will see that there are enormous
benefits to be had here and, like any other technology, as long
as we regulate it and regulate it well, starting cautiously and
moving forward, I think we can do it and I think we can do it well.
So to sort of wrap up and I do apologize for sort of going
over all of this very fast, I think there is a way to go forward. I
think we can learn from the past. I think we can see ways in which
small steps can be made. We need to respect one another's points
of view, but we need to listen and we need to be able to compromise
with each other. But let's not simply prohibit all of it.
Let's just find a way to do it right. Thank you.
CHAIRMAN PELLEGRINO: Thank you very much, Professor
Churchland. Professor Churchland's remarks are now open for
discussion. If you'll just signify your willingness to comment by
turning on the light and we'll try to keep everyone in our minds.
If we miss you, get our attention.
PROF. MEILAENDER: I have some other more specific
questions I may get a chance to get to later, but there's just a
general question I wanted to ask first because I'm puzzled. I
didn't think that we'd asked you to give us a suggestion about
a way forward. I thought we had asked you to clarify the concept of
dignity. And I guess I'd like you to say a little bit about what
your remarks have to do with the concept of dignity because I'm
sort of baffled by that.
DR. CHURCHLAND: I think that's a fair question.
And let me try to address it in the following way. I began with
the notion of the concept of dignity and what I really wanted to
stress is that it's not that there is a kind of language-independent
or community-independent notion of dignity that lives in Plato's
realm, that, as I tried to sort of indicate and I do apologize for
doing it in a rush, is that the notion of dignity changes over time.
But I suspect and I don't know whether Mike would agree with
me on this, but I suspect that the fundamental dispositions to respect
one another, cooperate with one another are very biologically deep
and if perhaps that's where dignity resides, then fine.
My guess is that that's where at least the notion that I understand
by respect and I think that's pretty close to dignity, I think
that's where that resides. And I think that's probably
why although we see enormous differences cross-culturally in specific
standards, how justice should be done and whether you should have
trial by jury or trial by ordeal. We see all those kinds of differences.
But fundamentally across all cultures you see this capacity and
this willingness for respect for one another, for understanding,
cooperation, sharing and also for willingness to punish the miscreants.
So I have the feeling that the notion of dignity is very
deep. I think that it is part of our social, our biological social
PROF. MEILAENDER: Well, there is an awful lot of human
history that might suggest the opposite about that willingness to
respect each other, but if I understand your answer, then what
you're saying is there really isn't some concept such as human
dignity. It's just that we're more or less wired to listen to
and respect each other. That's what the concept means, neither
more nor less than that as far as you're concerned?
DR. CHURCHLAND: Well, not exactly because I think built on
this fundamental platform, of course, different cultures at different
times add their own pieces and their own dimensions. One of the things
that I did in struggling with how best to address the issue of dignity
was just to talk to a whole lot of people outside of the Academy
because they tend to — anyway.
And so I talked to all kinds of people and asked them
really what they had in mind. And the thing that I found very striking
about this little piece of sociology which is not a controlled
experiment, is that people did exactly what the OED does. It starts —
they start by giving you examples. One person, a corporate lawyer,
began by talking about dignity under conditions of terrible
humiliation. And so he talked about Martin Luther King. Other people
talked about dignity in the context of having the freedom to pursue
one's talents and choices. And then they would tell a story.
And so what I got was essentially a series of exemplars. This
is what I think dignity is. And then if I would press them, but
what do you really mean by that, they'd say well, I don't
know, which is, of course, the right answer. So that when you look
at the OED, what do you see? Well, they start with Chaucer and
then they just move on through a series of authors where they take
sentences out of a particular text where the issue of dignity arises.
And you can see development. These aren't exactly the same
in every instance. But the core of it all, I think, is the ethical
brain. It is what makes us want to cooperate, to want to be part
of the human community. Where that breaks down, I think, traditionally,
has been in-group versus out-group. So we are prepared to be cooperative
and to compromise and share within the group, but not so to the
And as the human community has come to know each other
better, those sorts of barriers have broken down and now people are
quite ready to be kind and cooperative and helpful to people in the —
as it were, the out group.
So I'm sorry if I disappointed you. But my aim was to
try to go at the notion of dignity, as I think it really lives and
breathes and then to suggest that because that notion changes, because
attitudes towards medical technology change, so I think that we can
CHAIRMAN PELLEGRINO: Gil has one more.
PROF. MEILAENDER: Just a very quick — I have to say I
still don't see that as helping too much clarify on the concept of
dignity, but I may come back to some other questions later, if I have a
chance. But I just think that's an astonishing account of the
world in which we live. It bears almost no relation to empirical
reality as far as I can see it.
CHAIRMAN PELLEGRINO: Dr. Carson.
DR. CARSON: Thank you. That was really quite
interesting. I have one observation and then one question. In the
example you gave of the cadaver and the fertilizer, that you were a
potential cadaver or potential fertilizer and I could see where you
were going with that in terms of the embryo being a potential human
being. However, it seems to me that the direction is incorrect. If,
in fact, the fertilizer or the cadaver were potentially going to become
a human being, I think we might treat it differently and we certainly
wouldn't be willing to disperse it or cut it apart if we knew it
was going to become a human being. So I think probably you have to
reverse the order of the sequence.
Now the question is in terms of the soul that you discuss
briefly and to greater detail in the writing that you provided, you
indicated pretty much that there really is no such thing. And my
question is, obviously, if there is such a thing it would be relatively
intangible and very hard to define.
What evidence would be acceptable to you that there was
such a thing?
DR. CHURCHLAND: Ah, well, I think that's
a great question. If there were a research program that could show
me that, for example, you needed to use the notion of a soul in
order to explain say decision-making or you needed the notion of
a soul in order to explain perception, then of course, I would be
persuaded. I mean I think it's an empirical question and so
it just seems to me — but, of course, it's also a very
private matter. But it does seem to me that the idea of a nonphysical
soul that separates from the physical body is something that's
very hard for us to countenance because we know that, for example,
when the brain is in the body and certain parts of it are damaged,
you lose visual perception or you lose memory or as Mike's work
shows that if the brain is split and you have two halves, to some
degree they can act independently.
And I mean I think the split brain work in particular, partly
because it was early in cognitive neuroscience, really made us realize
that there's something very fundamental about what the brain
is doing in all of these mental functions and that probably the
idea of a nonphysical soul which, of course, Aquinas knew was a
problematic idea and basically in a certain sense argued against.
This is not to say that there isn't something that
lives beyond. I mean I think what does live beyond are our colleagues
and our children and our culture and our ideas. And I think it's
also quite possible to have a very, so to speak, spiritual existence in
contact with the natural world and with culture and other humans,
without thinking that there is a nonphysical soul.
DR. CARSON: But basically it sounds like what you're
saying is there really would be no criteria from which — that could be
acceptable in the scientific realm that there was such a thing.
DR. CHURCHLAND: Oh, not at all. I would be happy to see
evidence, of course.
DR. CARSON: But what I'm asking is what evidence would
be convincing? It's sort of like the question you ask a child when
they don't want to bed and you say well, what would be a good
reason for you to go to bed?
DR. CHURCHLAND: Let me put the question this
way. I'm going to answer your question with a question. Suppose
I thought that as many people did until about 1950 that life involved
élan vital, a spiritual force, that livingness itself was an immaterial
Now suppose I ask you, you know, you don't think that that's
the case, so what would count for you as evidence that that was
the case? And you'd be hard put to it to answer because you'd
say well, look, we know now about life because we know about ATP
and mitochondria and RNA and DNA and cell membranes and trans-membrane
proteins and how cells make a group. And if I had to give you what
would be evidence for vital force? Well, I don't know.
I think we're at a point in science where we say much the
same thing about a soul which is that we're not closed-minded
about it. If there were a research program whose conclusion was
that, I'd look at it very closely. So it isn't a closed
issue, it's just that's where I see the probabilities lie.
CHAIRMAN PELLEGRINO: Dr. Schaub.
DR. SCHAUB: I wanted to ask you a quick question about one
of the instances in your presentation and then if you're willing to
take questions on the article that was distributed, I'd like to ask
you a question about that as well.
DR. CHURCHLAND: Sure.
DR. SCHAUB: The instance I wanted to ask you
about is childbirth and pain and the use of anesthesia. Hasn't
there been a backlash against the use of anesthesia in childbirth
arising not from religious figures but from women themselves? So
it seems that many women desire to bring forth their children in
pain and that they believe there is a connection between this great
pain and the great joy of childbirth and as a result, there's
been a return to natural childbirth. So I wonder if you could comment
on that and maybe tie that to some kind of sense of the dignity
DR. CHURCHLAND: That's a great question.
DR. SCHAUB: Do you want me to ask the other question now
or do you want to respond to that?
DR. CHURCHLAND: Let me answer this one in case I get
muddled. Of course, it's a choice. And if someone prefers not to
avail themselves of it, then that's — that is, indeed, their
The problem was that in the 19th century people wanted it
not to be a choice. They wanted nobody. And this included people who
had to have Caesarian sections.
Now I know of nobody who argues that in the event of a Caesarian, what
you want to do is avoid anesthesia. But the other point I think
is that anesthesia in childbirth in say the 1960s and 1970s was
often misused. And it was often convenient for obstetricians and
I'm sure Dr. Pellegrino can correct me on this, but it was often
convenient for obstetricians to anesthetize the woman and do it
quickly. And so quite rightly some women felt that maybe they'd
rather do it the old fashioned way.
On the other hand, if the pain is going on for days and
days and days as it can, and it is excruciating, as it can be, then
lots of women do still wish to avail themselves of that possibility.
Now the third and final point is that anesthesia, especially using
spinal anesthesia, is such now that you can have pretty much the
joy, you can have the joy of the pushing and you can have the joy
of immediately feeding the infant and having it placed on your tummy.
You're not confused, you're not muddled, you're not
asleep. You can have all that joy, but you don't have to have
well, I've done it. It's actually pretty darn miserable.
And I was pretty darn happy actually to have a little sniff of the
old NO there, NO2. I didn't mind that at all. And I was pretty
into childbirth and the babies and I still am, but I did not mind
at all. And I did not feel that my pain helped anybody or that
you know, I was closer to nature, my God, as a result of feeling
all of that. So I'm sorry, I took too long.
CHAIRMAN PELLEGRINO: I have in the following order:
Gomez-Lobo, Hurlbut, Lawler and Kass, hopefully as you appeared.
DR. GÓMEZ-LOBO: I have some more general comments and
perhaps a question dispersed here and there. And the reason is I want
to have a better sense of the direction of your presentation. At
times, it seemed to me that it was all geared towards the question of
embryonic stem cells, which is the great debate today in the U.S. And
But then what arises in my mind is the following question,
well, why invoke Aquinas in this context? I know that lots and lots of
people mention Aquinas here and the big problem with Aquinas, of
course, was that he thought that the rational soul had no organ at
all. It came totally from outside the biological process. In fact, in
the Quaestiones Disputatae de Anima, he says it explicitly, that
it comes through — it comes out of the door, etcetera.
And then my question is well, why should we even think along those
lines. But the feminine ovum was discovered by von Baer in 1827.
The 50-50 contribution of the gametes was known by the middle of
the 19th century. And so that is something, I think, we should
take very seriously. Incidentally, the fact that Aquinas thinks
that the rational soul comes in at 40 days does not mean it's
morally permissible to destroy an embryo before 40 days. He thinks
it's a grave sin. It's just not homicide. So in a way,
one can say he had the ethics right, but the embryology wrong or
something along those lines.
Now in the case of our modern understanding of embryonic
development, it is true that there are continuities, but there is this
big break between the gametes and the zygote. The genetic structure of
the zygote is dramatically different from that of the gamete. So
there's an interruption of continuity there.
Now the other thing that seems to be pretty clear is that
there is something we can vaguely call a genetic program in the zygote,
the heredity goes through that stage and that therefore in terms of
genotype at least, it's undeniable that we go back to the zygote
stage. And in that regard, I side with Ben on this one, to say I'm
a potential cadaver, but I'm not a cadaver. I find that
tremendously puzzling because the idea of potentiality is the idea of
an active power to become something. One can say that the newborn
child has the potential to see and start seeing after perhaps a couple
of days or a couple of weeks, but death and becoming a cadaver is the
loss of all potentiality. There's a drastic dis-analogy there that
should be taken into account.
Now finally, not to extend myself too long, the question of the
use of the term "person," I think to a great extent, the
debate in the U.S. today hinges on the fact that the term person
is used in two different ways. It is used by some people as a phased
sortal as they say in philosophy, as a term that tells us what sort
of thing something is during a phase of its existence. A little
bit like a teenager, a teenager is a phased sortal. A phased sortal
is a concept such that if one ceases to fall under it, one does
not cease to exist. But a proper sortal is different. A proper
sortal is such that if one ceases to fall under it, one ceases to
Now taking into account — if one takes that into account,
of course, people would think that a human being has dignity and
therefore is owed respect throughout her life, of course we'd
be using the term "person" as a proper sortal. In other
words, it would be tied to the notion of human biological individual.
And there, I think, the genetic evidence is rather clear. Particular
DNA starts at fertilization.
So I would draw a rather different conclusion and the —
but the final point that I want to make is this. Someone can say yes,
you think that, but let some time pass and we'll come around and
it's going to be like anesthesia. But I rather doubt it. I think
that here we're at a very crucial and deep point which is you know,
hardly, hardly such that we could abandon it rationally.
DR. CHURCHLAND: Thank you. Wonderful questions, all.
The point about Aquinas was really introduced to remind us that
there has not been a univocal position amongst people with religious
beliefs on this question.
And the point about the rational soul for Aquinas and
it's easy to find the textual data, is that he says the proper —
it does come from the outside, but the proper organs have to be in
place, otherwise, the rational soul can't have a home and God
wouldn't do that.
So really I wanted to make two points and one is then that
even amongst highly respected theologians, there are differences of
opinion and that arguably Aquinas' point does mesh with a current
conception. All right, let's put that aside.
Second point, there's a radical discontinuity between
the gamete and the conceptus. There's a radical discontinuity when
cell differentiation begins, as radical from my point of view. Why
not? There's a radical difference once neurons and neural networks
begin to develop.
It all depends in the way, in what you really mean by radical
discontinuity and whether you wish to press the idea of there being
a discontinuity such that you don't have a person and suddenly
you do in the proper sort of sense, or whether you want to see that
there are many, many changes here. And what I don't think you
want to do is to bring to the debate a prejudgment about which of
those discontinuities for say religious reasons we're going
to take as serious and which we aren't.
What I'm prepared to do is to say let's look at the
empirical data, let's assume that there are differences of
opinion. Aquinas and I have an opinion about the importance of the
brain and the fetus for the rational soul. Your opinion is different.
I grant you that. Let's come together on it.
I think that's the main point.
DR. GÓMEZ-LOBO: A brief rejoinder. First of all, I feel
very uneasy about characterizing the discussion as a discussion of
religious opinion. Aquinas borrowed all of this from Aristotle. As
far as I know he never did any empirical work on embryology. It's
not a matter of theology. It's not a matter of belief. It's
not a matter of religion or of biblical background. So I'm totally
Let's look at the empirical data, but there, I think that
it is perfectly possible to give an argument to the effect that
say the development of the neural system is certainly caused by
the genetic program in the individual, whereas in one gamete, of
course, there's nothing of that nature. The two events, the
two changes are radically different. Empirically, I don't see
how they can be put on a par.
CHAIRMAN PELLEGRINO: Dr. Hurlbut.
DR. HURLBUT: I want to talk about the question of
potential and progress and I want to try to get back into the heart of
what I think you brought to us, specifically in the paper which really
does address some very fundamental questions about the foundations of
First, however, I'd like to make a point or ask a question,
it's sort of preliminary. It seems to me that there's a
sense in which the term "I'm a potential cadaver"
does not have the same meaning as, as Alfonso said, an organism
with a program to unfold in a certain way can become something.
And correct me if I'm wrong on this, but it seems to me, none
of us are potential cadavers. We have a capacity to die and then
cease to be. In that sense, we're never a cadaver. That would
like saying we are molecules. We have a capacity to die, but we
are never cadavers. Do you see my distinction there?
DR. CHURCHLAND: Up to a point. Look, much of
this depends on how you choose to use the word "potential."
And I don't think — like I think many concepts that are
useful in the workaday world, it doesn't have necessary and
sufficient conditions. And the point was made earlier that if something
has potentiality, it must be an active process; like who says?
I mean I think if you look in the dictionary, you're not going
to find that. That may be a particular conclusion that you wish
to have in the context of talking about the potentiality of the
conceptus, but it isn't a word that affects the notion, it isn't
a sense that determines our use of the word "potential"
People talk about so-and-so's potential for madness, or his
potential as an artist. We talk about the potential for energy
in a particular development. We talk about the potential for sea
rising, given global warming. We use that word in many, many ways
and it's not confined to the discussion of the development of
So the only point I wanted to make and it's essentially a
point that Mike makes much better in The Ethical Brain
and that is, even granting that there are continuities with some
differences such as the beginning of cell differentiation and so
forth, we don't want to say that the thing at this end is exactly
the same as the thing at this end or should be treated as such because
it has the potential to be such. I don't see the rationale
DR. HURLBUT: Okay, I will go on from there,
but I think you make an important point. There are different ways
to view potential, but that the reason the concept of potential
in the embryo is important is because it's used in a specific
limited sense and that is an active potency, an unfolding of being.
Just as we wouldn't say that a four-year-old girl was infertile.
We'd say her fertility is in her, but not yet expressed. We
would likewise say that reasonably that there is an active potency
toward a particular nature of being expressed that an embryo is
incipient, is an incipient form of an unfolding being.
DR. CHURCHLAND: Well, I hate to get sort of all Aquinas on
you here, but if we're going to go into philosophical territory, I
just might do that.
Look, Aquinas made several distinctions about the very
notion of potentiality. There was the first order of potentiality and
the second order of potentiality and we don't really want to have
to go into that here because I think that would bore everybody to
tears. But suffice it to say these are very, very different kinds of
notions and the first one he says is where the conceptus has the
potential to be a person. And the second one is where the infant has
the potential to be an adult and he views those in very, very different
ways. And it's essentially based on the biology, albeit a fairly
old and ancient biology. But there isn't a sort of single right
way to use the notion of potential.
DR. HURLBUT: Okay, what I really wanted to ask you was
this. In your paper, you speak of moral progress and you also at the
same time speak of our evolved moral capacities as basically serving a
utility function, of social cohesion and so forth. As you obviously
know, there's a huge debate about what the origins of that concept
Why in this sense is it meaningful to speak of progress at all?
Is it because it increases general social utility, individual benefits?
Or is it because it ascends towards some larger reality?
What I'm getting at here is the question that in spite of
the fact that you repeatedly in your paper seemed to imply that
the brain is a causal machine, that there is some kind of a computational
power going on, you also make reference to the use of reason and
so forth and I think these are very crucial questions when it comes
to human dignity, because there's the question of human freedom,
human ability to transcend those things which seem to be on an evolved
basis. It's almost as though you're pulled, like most of
us are in this debate, between the sense that there's a cold
calculation of evolutionary benefit and some transcendent goodness
that represents moral progress.
Do you see what I'm getting at? Is there something of a contradiction
DR. CHURCHLAND: I really do look at things biologically, I
have to confess. I thought very hard about that sort of question
because it's a very deep question and for anybody who does approach
ethics from a biological point of view, you have to think about it.
And my feeling is that we count things as moral progress to
the degree that they really enhance human flourishing and that by and
large the flourishing of the group entails the flourishing of
individuals, that when the group does well, it does well because
individuals do better.
And consequently, I think that, for example, having a judicial
system where you're tried by a jury of peers, is much more conducive
to — let's put it this way, less turmoil, less revolution
and so forth, than a system where people are — use trial by
And that many of these changes that we count as moral progress
are such because they reduce social turmoil. They make it possible
for people to achieve things. There's this great scene, the
best scene in Romeo and Juliet happens at the beginning.
What happens at the beginning is, of course, the idiot Montagues
and the idiot Capulets are having this tremendous row for no good
reason. It's just two warring factions, in-group/out-group.
And the prince comes in, settles it, sends them on their way.
And I think it's a great scene because I think in part what
Shakespeare is telling us is that you want to have a system of authority.
It doesn't really much matter necessarily how it comes into
being, but you must have a system of authority so that people don't
take the law into their own hands. And that's why a police
force is a good thing. And that's why legislation is a good
thing and so forth. We do not want the Hatfields and McCoys. It
causes tremendous problems.
If we don't have a judicial system, then when a child
predator does something really terrible to a child, I can bet you and I
would do it too, I'd go after that guy with my bare hands, if we
didn't have a judicial system in which I largely believed.
So I think it isn't a transcendent sense, but it's
a sense of progress that's very historical, but takes very
seriously, as Aristotle did, the idea of human flourishing and of
institutions and conditions that make it possible for humans to
I mean bear in mind, child labor was bitterly — the
legislation against it was bitterly opposed. If you go back and look
at the arguments against women's suffrage, all hell was going to
break loose if woman had the vote. Well, some people still think that.
But in any case, it counts, I think, as moral progress when
— and it isn't always moral progress. Sometimes, we take a step
we think is progress and we realize maybe that wasn't such a good
idea and we have to revise it and change it. Not all movement is
And sometimes you can't tell until, as Dewey, a great American
philosopher, said, you view it as a social experiment and hence
you be as cautious as possible, but you view it as an experiment
to see whether social flourishing will be enhanced, whether the
possibility for individuals will be enhanced. And guess what?
Public education introduced in the 19th century did despite great
misgivings, enhance human flourishing.
So that's kind of — that's a long answer and yet
it's also a short answer, so I'm sorry. That's the best I
could in quick time.
CHAIRMAN PELLEGRINO: Dr. Lawler?
DR. LAWLER: Thanks a lot for a great presentation.
And let me restore Professor Meilaender's question, sort of.
Your view of the world is altogether too happy.
DR. CHURCHLAND: Nobody has ever accused me of that before.
DR. LAWLER: Right, right. It's probably a continuum
of happiness or something. But it seems to be something like this.
With appropriate qualifications which you just introduced, the world is
constituted by progress and technology. The more we control, the more
we understand. Superstition recedes and our natural capacity for
respect, dignity and cooperation and all that comes to the fore. And
so the world is basically constituted by moral progress. And I think
there's some truth to this.
On the other hand, there's another way of thinking
which is something like this. Technology and biotechnology without
appropriate controls threaten our very humanity, our very dignity. And
in our world, where everything is constituted by choice, we have the
world of technology which is real and the world of preferences which is
the world that weighs nothing.
How can we control technology with mere preferences or mere
weightless choices? And this view is connected with say Nietzsche,
Heidegger, Leon Kass.
And these people at different levels for different reasons,
not all the same, these people worry that the unlimited progress of
technology, especially as it morphs into biotechnology, threatens the
very conditions under which human dignity is possible. I don't
completely agree with that view, but I don't completely disagree
with that view either. Isn't there something to it?
DR. CHURCHLAND: Of course, there is something to it. And
I don't entirely disagree. And that's why I was careful to say
at the end that we need to talk about regulations. We need to talk
about limitations. We need to talk about how to do this in such a way
that we don't have a biotechnology that goes out of control.
But if I may get historical again and please indulge me for just
a moment, catastrophizing technology is a long and distinguished
tradition. And we know, for example, in our — in the very
recent past, that many stories about the potential catastrophe of
genetic engineering came to the fore.
Now these were not unreasonable worries. What we need to do in
the face of reasonable worries is to have regulations, negotiate
how best to do it and that's why at the end I wanted to draw
attention to how it's been done in the U.K., not that I think
that there's no room for improvement. Obviously, there is.
But I think that you can't — look, we all know you can't
just say stop technology. I mean it isn't possible. My father,
way out there on the farm said we will have no television in this
house. Well, we didn't, but you know what? All our neighbors
did and so far as I can tell, television was a big hit.
You can't just say there will be no more progress in
this area. So whether you're talking about the use of fire or
gunpowder or nuclear weapons or whatever, there's always a terrible
danger and I'm very mindful of that danger. And in the case of
nuclear weapons, I've been especially mindful because I've had
the great privilege to know Herb York who negotiated the Test-ban
And so there are grave and terrible dangers. I would love
to put that genie of nuclear weapons back in the bottle, but believe
me, none of us can do it.
But I think we can, in the case of biotechnology, make good
decisions. That's not because I'm, you know, a Pollyanna. I
think we will also sometimes make bad decisions and have to take them
back. But as long as we're flexible so that we can cautiously move
forward, revise our decisions if they were unwise and try to do it
well, but you know, with the best will in the world, you are not going
to stop that stem cell research. It's going to happen. It's
happening in the U.K. It will happen elsewhere in Europe. The
benefits will be seen. So let's do it. Let's regulate it.
Let's be very careful about it. But I'm not that happy.
CHAIRMAN PELLEGRINO: Dr. Kass.
DR. KASS: I also want to stay on the dignity question. If
you even offer a small hint that the embryo question is on the table,
lots of my colleagues will see to it that it gets defended. It was no
part of your paper that was submitted. If it was, it was a tiny part
and I was, myself, much more concerned with the larger notion of human
dignity as is implied by your attachment to the neurosciences and your
account of the human being as brain with body and things of that sort.
Now I was hoping, given your paper, which wasn't really about
human dignity, that you would come and say look, human dignity is
a passé notion. We don't really need it and we can't defend
it, because it rests on an account of the human person that neuroscience
is now showing us is untenable.
If you looked at the OED, there are examples, but each of those
examples is pegged to a prior definition that's offered, all
of them sharing some sense of elevation, of worth, of excellence.
And the excellence of the human person, of human beings, I mean
there are excellences of other animals as well, but the excellence
of the human being has something to do with the performance of specific
human activities in a particularly fine or noble or high form.
Not all of them other-directed, by the way. Aristotle's Ethics
is not primarily about the virtues of usefulness to the community.
In fact, not once in the account of any of those virtues up to justice
does he talk about the utility of them. He talks about their being
for the sake of the beautiful or the noble and the whole context
of the Ethics is individual flourishing and happiness.
So I would have thought that you would have said, the soul being
an unnecessary notion and that all there are are brains, that it
would be very hard to see how this particular neurochemical, neuroelectro-chemical
functioning carried anything like dignity, or what would make something
dignified as opposed to undignified?
And I don't think that you can sustain a notion of
human dignity on a purely material account of the human being. That
would be point number one.
Point number two, I can't resist on the subject of the soul.
I found it somewhat odd that Aristotle — that Aquinas'
teaching of the soul was sort of imported here for its utility,
but against a background where one thought that the notion of the
soul was utterly passé. And it's true that none of us believe
in the vital élan, although I don't think the account
that we now have of the materials of life add up to an account of
what aliveness is, but that's another subject. But that's
partly because the problem as posed in the middle of the last century
was to see what would be left over after you conceded a full mechanistic
account of the body, and then these poor fools tried to invent some
kind of ghost in the machine that somehow explained the things that
mechanism couldn't explain.
But for real proper discussion of the soul, you need to ask
what in the world does it mean, what do you mean when you're
talking about it? And Aristotle's account of the soul is not an
account of some kind of — I've forgotten how you chose to
embarrass treatment of the soul. It's, in the first instance, the
form of the naturally organic body possessed by certain kinds of
powers. And it is not material. That is to say, and here I think
there's a demonstration, this is a philosophical point, not an
The philosophical point is and I don't think it's been
refuted, the eye, the eye has extension. De Anima 2.12.
The eye has extension. You can hold it in your hand. It has length
and breadth. You can measure it. But sight, the power of seeing,
you cannot hold in your hand. Never mind the activity of seeing
which is not a thing.
You can't see without the material thing, but to see, the act of
seeing — the brain doesn't see. You see as a result of
the brain being in a certain way. And that means that there's
much more that has to be done here before we yield to the neuroscience's
wonderful mechanistic account of mechanism, the full account of
the human person, because if we cede to them, then I think you have
to say human dignity goes with it. I don't see any way of saying
— I don't see any way of justifying your very nice person
amorality about cooperation and being nice and so on.
I mean there is the ape and the tiger that Thomas Huxley in Evolution
and Ethics reminded us too that has been somehow part of our
history. I don't think you can develop a notion of what moral
progress really is as opposed to simply saying there's change,
and you've got an account of what human dignity is, and I don't
think you can sustain a notion of human dignity on the basis of
neuroscience and materialistic neuroscience alone.
That's a bit much —
DR. CHURCHLAND: Oh, I think I can handle it.
DR. KASS: Okay.
DR. CHURCHLAND: All right, there is a lot to respond to.
Look, I stand upbraided. I did not say very much about dignity because
I tried to approach it in a different direction.
I did that for several reasons. One, as I said, I thought Adam
Schulman's discussion was extremely useful and I thought that
it also showed that there were rather different conceptions, historically,
I also thought that Ruth Macklin had dealt with many of the
issues about whether dignity is really the critical element to be
discussed. So I didn't want to do that again, otherwise I'm
sure I would have been upbraided for repetition.
So as I said, I asked myself how can I be most useful? And
I think if I had just given the same talk on the nature of dignity as
viewed by Nietzsche or Aristotle and then Kant and so forth, you would
have been even more disappointed. So I decided to — I should perhaps
have not come. I should have said hey, I've got nothing to say.
But I was not about to squander an opportunity to talk to this group —
— and also to meet some of you. So I asked — I mean
maybe this is just a pragmatist sort of question I shouldn't have
asked, but I said what could I do that might be useful? And so I tried
to do what I thought might be useful, knowing that I couldn't
expect agreement on everything, but hey, agreement on everything is
pretty boring. If you and I agreed on everything, you'd probably
wander off and talk to somebody else.
So I did my best. I stand scolded. Can we move on?
Now you wanted to say something?
DR. KASS: Forgive me if I was — if that
was received as a sort of aggression.
DR. CHURCHLAND: No, no, no. I just thought that you were
disappointed and I am very sorry to have disappointed you.
DR. KASS: No, I would like to ask this question.
Let me put it in the form of a question. You're steeped in
neuroscience and its implications for philosophy. And you've worked
in that area and are interested in neuroethics.
I wasn't expecting you to, say, repeat the history of philosophy
on the subject of human dignity. The question is what — on
the subject of human dignity, on whatever notion of human dignity,
do we have anything to learn from neuroscience if the brain is all
DR. CHURCHLAND: I know that's your question and
that's why I was about to move on. So you said, and this really,
really surprised me, I think, that you hoped that I would say that if
the mind is what the brain does, then there's no such thing as
dignity. And perhaps you hoped that because then I'd be a really
easy target, right? You could shoot that lady down.
But I wouldn't say that because here's how I think about
the brain. I think that it's an extraordinarily complex device,
which amongst other things guides movement and behavior, makes decisions,
remembers and remembers both in this declarative way that we know
and also in procedural ways and that when the brain is split, we
see disconnection phenomena that Mike has discussed and experimented
on so well. We know that in Alzheimer's it's not that there
is a nonphysical self that remains with all those memories and has
that reason and knows how to find the way home, we know that in
a seriously demented person those capacities are compromised and
they're compromised because the brain is compromised.
We know that when somebody feels pain we can ameliorate the pain
by changing various states of the brain. Now the problem —
and you know, no one knew this better than Descartes — the
problem with the idea that there is a nonphysical soul that somehow
does the feeling and the thinking and the remembering and it's
all intact, the problem has always been, as Father Malebranche said,
and I'm sure you must know this: So how does this nonphysical
thing connect to the brain? Where is the interaction?
And nobody has ever been able satisfactorily to give an account
of that. And not only not give an account of it, nobody —
and here's the interesting sort of real response to your question,
nobody even has a research program to show how that might be done. There
isn't even the merest beginning of a research program to show
how the nonphysical soul could interact with the brain. The only
neuroscientist or the only scientist that I know of that ever did
really was John Eccles and to his great credit he gave it a real
go. And he had the idea that the soul interacts with the brain
at the synapse, but neuroscientists find that deeply implausible
for all the physiological reasons that we know about.
So doesn't dignity vanish? No. Perception doesn't
vanish. Pain doesn't vanish, if we are a material thing. Pain is
as real as it would be if we were a nonphysical soul. It's real.
Memory is real and it's sure real when they're losing it and
don't have it any more.
And reason is real. We don't know in terms of the
nervous system what it is for neurons to get together and reason. And
respect that we hold for one another is like love that we hold for one
another. It's real. It's what the neurons, under certain
So we can't, I think, at this stage of neuroscience, give
a detailed account of that, but we know that various hormones have
a big effect on that. We now know, for example, that if you put
a woman into a tent and let her sniff either estrogen or testosterone,
certain parts of her brain are more apt to testosterone and men
are the other way around, unless they're gay, in which case they're
more apt to — the part of the hypothalamus is more apt to
So we're beginning to sort this all out, but it
doesn't mean that you know, we're just like a lawn mower. We
are an extraordinary device, all nervous systems are. I mean it's
like saying how can it be if temperature is really just motions of
molecules, how can it be that just motions of molecules can make water
boil? That makes no sense. There must be caloric fluid or something.
Sometimes science surprises us by telling us that our
intuitions about certain concepts need a bit of a change and I think
perhaps we're learning. I mean this is sort of the great
revolution in philosophy right now. We're learning what it means
for us to understand ourselves and we're not the only culture who
does. I mean primitive cultures have done this too, who have
understood ourselves primarily as material beings with these
wonderfully complex capacities.
I'm sorry I took too long.
CHAIRMAN PELLEGRINO: We have the following who would like to
speak: Dresser, McHugh, Rowley, George and Gazzaniga. The time is
short. May I suggest the following? I would like to give everybody
I've listed a chance to ask your question. Would you be willing to
take a couple of questions together, instead of taking them one by one?
DR. CHURCHLAND: And I will be very brief in my response.
CHAIRMAN PELLEGRINO: If we can do it that way, we might be able
to get it all worked in. So I'm going to ask Dr. Dresser to kick
off and then Dr. McHugh.
PROF. DRESSER: All right, I'll try to be really fast.
I guess — I think you've had a difficult job and part of the
frustration you may be hearing is because we are facing a frustrating
task of what do we do with this dignity stuff?
And obviously, it's relevant to a lot of bioethics
concepts, beginning of life and we've put out three, four reports
on some issues surrounding that.
I wonder if you have any thoughts about topics such as use of
drugs and other medical interventions for "lifestyle purposes,"
things like selling organs; of course, death with dignity, and part
of the problem is people on different sides of arguments use the
As you say, Ruth Macklin has written about this, but I
don't think the debate or the analysis has been exhausted, so I
wonder if you have any thoughts about those theories?
CHAIRMAN PELLEGRINO: Thank you very, very much. I think there
may be some overlap and we'll give the doctor a chance.
Dr. McHugh, you're next and then after that, Dr.
DR. MCHUGH: Well, it was terrific, Pat, and you're
still your old sassy self.
Welcome and all. What I wanted to say to back up some of these
other issues, maybe we're talking about two domains of knowledge
and you are committing yourself to the domain of science or that
science philosophy. Yet, when you come to explain yourself, you
turn to the poets. You turn to Shakespeare to tell us the value
of the legal process, after all, but that's not new with Shakespeare.
The Oresteian tragedies lead up to exactly the same point. And
yet, in your discussions, you spend an awful lot of time walloping
the religious folks, except coming down for what you consider the
better cite, Catholic philosopher Aquinas, and not me.
I'm an Augustinian, but that's besides the point.
And you point out various things about what one Pope did
and another Pope did. After all, there was another Pope Clement who
very much spoke about autopsies, the important things, that he played a
bit role in the black death issues. The reason I feel about that is
that I was at the Brigham in 1956 when they were doing — I was a young
intern at the Brigham, when they were starting to do the twin
transplants and we heard this and then we went to look, it was just as
you said, he wasn't stopping that. He was worried about the
possibility of selling and buying things.
And by the way, Jack Kevorkian, one of the things Jack
Kevorkian spoke about is that we should chop away at the people
we're going to be executing because after all, we could use their
organs and then kill them. So he was prescient.
I wonder, in the process of talking about human dignity, two things.
Why you aren't talking about how the scientists get it wrong
so often. After all, from Semmelweis showing people they ought
to wash their hands and he couldn't persuade the doctors to
do it and was ostracized in Vienna for that, through eugenics and
frontal lobotomy and now we have this sex change operation, all
of which come from scientists. What is it about the scientists that
they don't speak the way the poets do in relationship to this?
So that's the first question. And maybe you should be talking
more about what the poets tell us because they provided domains
of knowledge that maybe biologists, you and me, can't get to
And the second little question is look, in the dignity question,
can you do as well as Jefferson did and bring us up to some sense
of where we are, created equal, endowed with certain inalienable
rights? After all, that was the position that permitted a tremendous
amount of progress to occur in our culture. And the Lincoln-Douglas
debates are all on that. I'm not telling you something you
So why don't you wallop the scientists for a bit to
find out in what way they get us into trouble and then talk about
whether some cultures are better than other cultures because of the
poets they listen to?
CHAIRMAN PELLEGRINO: Thank you, Paul.
DR. CHURCHLAND: Okay.
CHAIRMAN PELLEGRINO: Dr. Rowley.
DR. ROWLEY: I appreciated your comments very much and I
want to ask you to follow on with the sense, as you have described
human dignity or in a sense where man flourishes best, what kind of
implications that has for our society and for the kinds of concerns
that society should have? And I'm thinking particularly in terms
of children and the poor in both health care, education and things of
CHAIRMAN PELLEGRINO: Thank you very much. Dr. Gazzaniga?
DR. GAZZANIGA: Well, Pat, thank you again for a wonderful
talk. It certainly has provoked great interest.
I would like to offer a way of thinking about human dignity that
is similar to the difficulties of thinking about a concept such
as, say, personal responsibility and what I heard you saying today
can be illustrated in the following way to get us to think about
this. Let's imagine that everybody in the room here is the
only person on earth. You are the only person on earth. Then there's
no concept of personal responsibility. There's no concept of
human dignity. You're not going to strut over to a tree and
say hey, show me some dignity.
All of these things are obviously social constructs that
come from a group interacting and the rules that we set down and confer
on these concepts are as a result of hypotheses and attitudes that we
engender towards each other because we live in a group. So in my
analysis, the neuroscience really does not speak so much to concepts of
human dignity and of personal responsibility as does the hypothesis
that we generate as a result of living together in a social group. And
so we're looking, we're chasing the wrong dog here.
What we should be trying to understand is the social ideas
that come out of groups living together and that's where these
concepts are held.
CHAIRMAN PELLEGRINO: And now
Dr. George and that will be the end of the questions and then the
terrible task I've imposed on our speaker to respond to all
of you in a very brief time.
PROF. GEORGE: Thank you. Dr. Churchland, I
do want to raise the issue of personal responsibility. I'd
like to know what the implications are for personal responsibility
of the rejection of the contracausal view of rational choice. I
thought that one way that we might be able to get at it is just
to ask you whether the following proposition is true or false or
meaningless. I just want to take a situation of moral monstrosity.
Hitler chose to do wrong in killing, murdering millions of Jews
and others. He didn't have to do it, but he did it. And because
he did it, he deserved to be punished.
So can I accept the Humean view that you accept and still say
that that proposition is true or is it false or is it meaningless?
DR. CHURCHLAND: Sure, it is true. But I'll come back,
see if I can do this quickly.
CHAIRMAN PELLEGRINO: Thank you.
DR. CHURCHLAND: Now the first question, drugs and
lifestyle and selling organs and so forth, I think these are things
that we, of course, need to regulate. But these are really, really
complex questions, but the selling of organs, of course, is very
tightly regulated and certainly in our country, but so far as I know,
pretty generally. And you really don't want to have to do that.
Death with dignity, yeah, I think we probably all have
different views on that. But I guess it's a really big question
and I know that many of you have struggled with that. So I guess I
won't say too much about that. But maybe you and I can chat a
little bit outside.
Okay, so the Augustine scholar, science gets it wrong.
Absolutely, science does get it wrong. And there are lots of instances
of that. So that was why I kind of wanted to say it isn't always
progress and sometimes what looks like progress turns out not to be
such a good idea and you realize the need for regulation.
So you do want to have regulations. I mean I'm really one
of those people who doesn't think that everyone should just
have a free hand, that we should down-regulate everything and let
folks go. I think we do need to negotiate together.
We need to compromise and come to reasonable conclusions
about what can and can't be done. And I think we've done that
on organ transplants, for example. I think that's actually worked
extremely well. I mean one of the things you require there is that the
doctor doing a transplant has nothing to do with the patient who is
giving it up.
Okay, so dignity and flourishing, of course, does involve,
as you're quite right, it does involve many, many aspects of life
and I kind of picked up from your question and I might be wrong about
this, that you made me think that there are other sort of deeper and
more pervasive problems than the problem of deciding whether the
conceptus has the rights and privileges of a person, that maybe we can
come to agreement on that, move forward and then maybe address some of
the deeper problems of poverty and unwanted children and so forth.
Okay, and then there was Mike Gazzaniga's question and
I think he just puts it a lot better than I do, but I think I basically
agree in the sense that the disposition for cooperation and respect,
that's part of what we have and we're selected for as social
animals. And then the particular configuration that we give to that
via our institutions of a variety of kinds depends on accidents of
history, on how people think about things, about what their empirical
hypotheses are and their general attitudes.
So that's why I think we can expect to see differences
and why we shouldn't think the differences between us on say the
dignity of the conceptus is telling us anything deep. It's just
that people disagree. And finally, can we hold people responsible on
the assumption that the brain is a causal machine?
What I wanted to argue for in the paper was absolutely that —
and let me just go back to evolutionary biology. I mean one of
the things we do know is that if you want social traits of cooperation,
sharing and so forth, compromise, to spread throughout a population,
you have to punish the miscreants, because if you don't, they'll
And so if there ever was a justification for punishment in
terms of social utility, that's it. And I don't foresee that
going away, at least not in the immediate future, so I think that is
the justification for punishment.
Now the particular forms that punishment takes is going to vary.
I mean some people swat their children, some frown, some pinch them
and so forth. And with regard to capital offenses, some people
still like public executions. Others don't want executions
at all and then there's everything in between. So the particular
form that punishment takes is going to be negotiated and reasoned
about and empirical information about say the nature of madness
and the nature of genes like MAO-A mutants will come and will be
relevant and then we'll just have to do the best we can.
PROF. GEORGE: I am sorry, Dr. Churchland, I
think I made myself misunderstood then. I wasn't asking whether
you believed in whether there was a justification for punishment.
I was asking whether you believed that there could be personal responsibility
if you accept the Humean view, so my exact question was, is the
following true or false or meaningless: Hitler chose to kill millions
of Jews and others. He didn't have to do it. Because he did
it, because he did it, not for some future utility, but because
he did it, it's a retributive question, a question about retributive
justice, he deserved to be punished.
DR. CHURCHLAND: Well, my view on retribution
is very different from Richard Dawkins's. I think it serves a very
important social function. I think people need not only to have
a system of justice, but they need to see someone who did something
truly terrible, they need to see them punished. And if they don't
see that, then they take justice into their own hands.
So I think there's a powerful need for retribution.
You see it in baboons, chimpanzees, dolphins, wolves, and you see it in
us. And I think if you set up a system of criminal justice where you
just send the really terrible ones off to a nice farm, all hell would
PROF. GEORGE: But would there be a reason to punish Hitler
if there would be no social utility in doing so? I'm trying to get
DR. CHURCHLAND: I think it's within the broader
utility, of course, it has to be.
PROF. GEORGE: So it's not because he did it, because
he's personally responsible and he deserves it.
DR. CHURCHLAND: Our understanding of "personally
responsible" is embedded within this broader context. That's
my take on it. And I mean look, there isn't a Platonic heaven
wherein the notion of pure justice, in and of itself, resides.
It just ain't so.
PROF. GEORGE: Well, I didn't
know that I was implying that it is, but I did want to know whether
Hitler chose to do it or didn't choose to do it and whether he is
responsible because he chose to do it and whether he should be punished
because he's responsible.
DR. CHURCHLAND: What do you think?
PROF. GEORGE: I think the answer is yes, that he did it.
Didn't have to do it. Because he did it, he's responsible and
he should be punished, irrespective of any social utility in punishing
DR. CHURCHLAND: It's not the social utility of his
particular punishment I'm talking about. I'm talking about the
institution of punishment itself. And for the institution of
punishment to work, individuals have to be punished, ergo, I would
punish him and for the reasons you say.
CHAIRMAN PELLEGRINO: Thank you, very, very much for a valiant
effort. I'm going to take the Chairman's prerogative of saying
we have a little extension of time, let's come back at the hour, 11
o'clock, and we have a little flexibility toward the end and thank
you all for your comments and I'm sorry, I couldn't get any of
mine in. Thank you.
(Laughter and applause.)
(Off the record.)
SESSION 2: THE CONCEPT OF HUMAN DIGNITY
CHAIRMAN PELLEGRINO: We are about to move to our second speaker
for the morning, Dr. Daniel Sulmasy, and again as with our other
speaker, you have a complete or fairly complete, quasi-complete
curriculum vitae in front of you for the details. Dr. Sulmasy is a
physician who is still seeing patients, the Director of the Center for
Bioethics at St. Vincent's Hospital in New York and at New York
Medical College as well. He also is a Franciscan Friar. We've
asked Dan to reflect on the concept of dignity as seen from the
classical point of view and religious point of view as well.
Dan, lest I take more of your time, I think you can take it away.
We have one or two Council Members who I'm sure will be here
and will not miss anything too vital unless they stay out more than
DR. SULMASY: Well, I'm honored to be here, actually,
among so many former teachers and esteemed colleagues, both in medicine
and medical ethics. And I'm going to try to do three things this
morning that I hope will be useful to the Council, but given the brief
time I'm allotted, I'm going to present them in a fairly
compressed, abbreviated form and may wind up speaking too quickly here
to do that.
The first thing I want to do is provide my own outline of a
history of the philosophical uses of the word dignity, particularly as
it relates to religious uses. Second, sketch at least an argument
about the meaning of dignity on the basis of consistency and its use.
And third, to sketch an argument about the meaning of dignity based on
theory of value.
So dignity appears to be an important concept in ethics.
All of you are aware of this. It occurs in documents like the
Universal Declaration of Human Rights at the U.N., the European
Convention on Human Rights and Biomedicine, and even somebody like
Dworkin has noted that the very idea of human rights seems to depend
upon what he calls the "vague, but powerful idea of human
So the history part first. The word dignity has an
interested history in Western thought and I apologize for the very
whirlwind tour I'll give and I could expound on these things, if
you want at length later.
While it's often argued that the idea of dignity is
essentially religious, and I know this argument has recently been made
before you, the first place that I want to start is with scripture
where it's very hard to make that argument at all. The Hebrew
translated as dignity, gedula, occurs rarely in the Hebrew scriptures
and it means they are something more like nobility of character or
personal standing in the community.
The Greek word, semnotes, occurs only three times in the
whole Christian scriptures and it's best translated, most people
would say, by the word seriousness.
Aquinas uses dignita s and its cognate, 185 times in the Summa
Theologiae, and I read them all, and it tends to mean the value
that something has proper to its place in the great chain of being.
So plants have more dignity than rocks and angels have more dignity
than human beings, sort of the way he uses it.
In a nutshell, while Christians may always have had some
concept of human dignity, until very recently, it "had not been
developed into either a clearly defined literary form or an internally
consistent set of ideas."
Now Aristotle uses semnotes only three times and not at all
in the Nichomachean Ethics. In the Eudemian Ethics, he
defines dignity as a virtue, the mean between servility and
unaccommodatingness. That's sort of hardly the way we tend to use
the word today.
Roman stoics, particularly Cicero and Senecca made copious
use of the word. Recent translators would note that for the Romans,
the Latin word literally meant worthiness. And in its common political
sense it meant a person's reputation or standing.
It's the Renaissance writer, Pico della Mirandola, who's
credited with making the first connection between human freedom
and dignity. By contrast, Hobbes tied dignity to power. He wrote
that "the value or worth of a man is, as of all other things,
his price; that is to say so much as he would be given for the use
of his power."
In turn, Hobbes offered this definition of dignity:
"the public worth of a man which is the value set on him by the
commonwealth is that which men commonly call dignity."
Now although he never cites him, Kant's notion of dignity
seems to be a response to Hobbes. Kant writes, "the respect
I bear others or which another can claim from me, is the acknowledgement
of the dignity of another man, that is, a worth which has no price,
no equivalent for which the object of evaluation could be exchanged.
He insists elsewhere, "humanity itself is a dignity."
Now the Kantian notion probably has a more familiar ring in the
21st century, but it's another long story and if you want, I
can go into more detail on that in the questions. I can trace how
the Kantian idea of dignity was married to the notion of human beings
having been created in the image and the likeness of God by a Kantian
theologian in the 19th century named Antonio Rosmini, and it subsequently
made its word into Catholic theology and was first explicitly used
in the encyclical Rerum Novarum in which Leo XIII defended
the dignity of workers in the 19th century.
Before that, you have almost no Catholic Christian use of dignity the
way it's used today. And thus, it's actually by a retrospective
baptism of a Kantian idea that dignity became the important word
it is in, particularly Catholic, but other forms of Christian thought
today. Very late.
Now given the history I've just very sketchily outlined, it's
clear and from Adam's paper as well, that many people have historically
used the word dignity to mean different things. And I want to suggest
for you, and this may be helpful to the Council's work, a convenient
way to classify those uses. And the way I'll do it and it's
a development from the paper I gave you, is to distinguish between
attributed, intrinsic and derivative conceptions of dignity.
By attributed dignity, I mean the worth or value that human beings confer
on others by acts of attribution. The act of conferring this worth
or value may be accomplished individually or communally, but it
always involves some choice. Attributed dignity is, in a sense,
created. It constitutes a conventional form of value and thus we
attribute worth or value to those we consider "dignitaries,"
to those who carry themselves in a particular way or have certain
talents, skills or powers. We even attribute worth or value to
ourselves, sometimes, using the word this way. The Hobbesian notion,
I will suggest to you, is an attributed notion of dignity.
By intrinsic dignity, I mean the worth or value that people
have simply because they are human. Not by virtue of any social
standing, ability to evoke admiration or any particular sets of
talents, skills or powers. Intrinsic value is the value something has
by virtue of being the kind of thing that it is. Intrinsic dignity is
the value that humans have by virtue of the fact that they are human
beings. This value is thus not conferred or created by human choices,
individual or collective, but prior to attribution. So Kant's
notion of dignity would be an intrinsic notion.
By derivative dignity, I mean the way some people use the
word to describe how a process or state of affairs is congruent with
the intrinsic dignity of a human being. Thus, dignity is sometimes
used to refer to a virtue, a state of affairs in which a human being
habitually acts in a way that expresses the intrinsic value of the
human. This use of the word is not purely attributed, since it depends
upon some conception of the human that's prior to it. Nonetheless,
the value itself to which this word refers is not intrinsic, since
it's dependent upon this intrinsic value of the human.
Aristotle's use of the word is derivative and I think
so are a lot of stoic uses of the word derivative.
Now these conceptions of dignity are by no means mutually exclusive.
Attributed, intrinsic and derivative conceptions of dignity are
often at play in the same situation and yet each has been taken
as the central focus for particular claims in bioethics.
So next I want to sketch out an argument that to be
consistent in our use of moral words, to do the kind of moral work that
somebody like Dworkin wants the word dignity to do, to make good use of
the word in bioethics, that the notion of intrinsic dignity is the
And so the first argument is simple in its form. It's
to say that consistency is at least a necessary condition of an
argument, even if we wouldn't — we would quickly add that it's
not sufficient. And in discussions about its fundamental moral
meaning, then the word dignity can either be defined as the value or a
worth or worth that a human being has either in terms of some property
or in terms of simply being human.
I want to show that defining the fundamental moral meaning
of dignity is the value that human beings have by virtue of their
possession of some particular candidate property, leads us quickly to
inconsistencies in our universally shared and settled moral positions.
Therefore, I think we'll be led to the alternative, that dignity
is in its fundamental moral sense defined simply in terms of being
human. Now, of course, this kind of argument depends on the exhaustiveness
of the list of candidate properties, but at least it puts the burden
of proof on those who oppose assigning priority to the intrinsic
sense to come up with the alternative property. And if it's
not one on my list, you may say well, age or size or IQ, whatever
other property you want to give, to define the fundamental worth
or value of a human being.
So what sorts of candidate properties have been proposed? Well,
some have argued that human dignity in its most fundamental moral
sense depends upon the amount of pleasure or pain we have in our
life. And certainly, however, though I think again very quickly
here, most of us can tell stories of extraordinary lessons in dignity
that we've learned from persons whose lives have been racked
by pain and most of us also know very undignified human beings who
have spent their whole lives in pursuit of pleasure.
Merely basing our moral stand squarely on a balance between pleasure
and pain is seen, at least since the time of Aristotle, as a fairly
anemic account of morality and human dignity and one that most persons
Second, some people might think that Hobbes was right, that
human dignity depends upon one's social worth. But there are
problems with such a conception of dignity: the unemployed, the
severely handicapped, the mentally ill and all others who can't
contribute to the economic well-being of society and are cared for by
physicians would then have no dignity. Yet, our society, I think, has
gone to great lengths to recognize the dignity of such persons.
If we didn't believe that human dignity remains even if
people are handicapped and have lost their economic value to society,
we wouldn't be making handicapped access ramps for them.
Third, some people might think that dignity depends upon
freedom, but again, I think this is a hard view to take consistently.
You'd have to hold that those who have lost control of certain
human functions or have lost or who have never had the freedom to make
choices have lost or never had dignity. And this would mean that, for
instance, infants, the retarded, the severely mentally ill, prisons,
the comatose, perhaps even the sleeping, would have no dignity and I
think that would be wrong.
Now some might suggest that what counts is the capacity for control
and freedom, not the exercise, the active exercise of it. One might
suggest that some individuals without full control and freedom,
nevertheless deserve to be treated with dignity, either because
they have a potential for such a capacity so that, for instance,
children come to be regarded as placeholders for actual bearers
of dignity or they have a history of having exercised such a capacity,
so that the demented come to be regarded as remnants of those who
But I think those arguments are quite tenuous too. You
might recognize where they come from. But who would feel dignified and
secure being named a placeholder or a remnant?
Further, these arguments still can't answer why those
who never could or never will make free, rational choices, such as the
severely mentally retarded, are worthy of our respect? The fundamental
meaning of human dignity, I think is not found simply in our freedom
And the famous photograph of the Reverend Dr. Martin Luther
King, sitting in the Alabama prison cell, I think is a portrait of what
it means to have human dignity radiantly depicted, despite lost freedom
and lost control. Prison bars and the attitudes of others didn't
erase his dignity.
Fourth, some people might suggest that human dignity is
something that individuals are free to choose to define as they wish,
according to their own inner lights, but of course, that's the
ultimate conversation stopper. You know, you can't impose your
view of human dignity on me. But this also leads to inconsistencies.
First, I think the concept of a moral term implies that it has
universal meaning. That's a position acknowledged by both Kant
and utilitarians like Hare. Second, it means making it an objective
argument that morality is subjective which is internally self-contradictory.
And third, to say that human dignity is subjective is to claim that
one person can never reliably recognize the dignity of another person
because I can never know exactly what any of you think human dignity
means until you've told me what it means. But I think we all
recognize dignity or value in each other before any of us opens
our mouths. And so I think human dignity can't be a purely
Thus, all the argument from consistency would claim is that
a fundamental human dignity must therefore be something that we have
simply because we're human. It's a notion that drove the civil
rights movement in this country. It's the notion that Martin Luther
King said he learned from his grandmother who told him this is what
dignity means, Martin, don't let anybody ever tell you you're
not a somebody, that being somebody, not the properties one has, not
the color of one's skin or being free to do what you'd like, is
what gives you dignity, because you are a somebody, a human being.
And that's the foundation — and if that's the
foundation of the notion of dignity in the civil rights movement, the
argument from consistency says that's what it ought to mean in
Now very briefly again, I'm conscious of the time here,
I just want to outline another way that was more developed in the paper
that we can arrive at a similar conclusion, an argument that depends on
the theory of value or axiology.
Classically, people distinguish between intrinsic and instrumental
values, but I think instrumental values are really a subclass of
attributed values. So the primary distinction I want to draw is
between intrinsic values and attributed. Intrinsic value is the
value something has of itself, the value it has by virtue of being
the kind of thing that it is. It's valuable, independent of
any values, purposes, beliefs, interests or expectations. Truly
intrinsic values, according to the environmental ethicist, Holmes
Rolston, are objectively there, discovered and not created by the
By contrast, attributed values are conveyed by a valuer.
Attributable values depend completely upon the purposes, beliefs,
desires, interests or expectations of a valuer or group of valuers. An
instrumental value, for example, is one that is attributed to some
entity because it serves a purpose for the valuer. The instrumental
value of the entity consists in its serving as a means by which the
valuer achieves some purpose. But there can also be noninstrumental
attributed values as well, like the value of humor, which doesn't
necessarily serve any clear instrumental purpose.
So the next step in my argument would be to say that if there
are intrinsic values in the world, then the recognition of the intrinsic
value depends upon one's ability to discern what kind of a thing
it is. And this brings me to the notion of natural kinds. This
is a relatively new concept in analytic philosophy, but I'll
just say this, there's more of it in the paper. But the fundamental
idea behind natural kinds is that to pick something out from the
rest of the universe, you have to pick it out as a something. And
this leads to what proponents have called a modest essentialism,
that the essence of something is that by which one picks it out
from the rest of reality as anything at all, as a member of a kind.
And the alternative seems inconceivable, that reality is
really just completely undifferentiated, that human beings carve up the
amorphous stuff of the universe for their own purposes. It seems to me
bizarre to suggest that there really are no actual kinds of things in
the world independent of human classification, that there really
aren't such things as stars or slugs or human beings.
And thus, the intrinsic value of a natural entity, the
value it has by virtue of being the kind of thing that it is, depends
upon one's ability to pick that individual out as a member of a
And so I define intrinsic dignity with a capital D, as the
intrinsic value of entities that are members of a natural kind that is
as a kind capable of language, rationality, love, free will, moral
agency, creativity and aesthetic sensibility. This definition is
actually decidedly anti-speciesist, because if there other kinds of
entities in the universe besides human beings that have as a kind these
capacities, they would also have dignity in an intrinsic sense.
Intrinsic dignity, as Dworkin suggests, is the foundation
of our concepts of rights. We respect rights because we first
recognize intrinsic dignity. We don't bestow dignity with a
capital D in this intrinsic sense to the extent that we bestow rights.
Human beings have rights have must be respected because of the value
they have by virtue of being the kinds of things that they are.
Now importantly, the logic of natural kinds suggests that one
picks out individuals as members of the kind, not because they express
all the necessary and sufficient predicates to be classified as
a member of the species, but by virtue of their inclusion under
the extension of the natural kin, that as a kind has those properties.
The logic of natural kinds is not set theory. For instance, very
few bananas in the bin in the supermarket, right, express all the
necessary and sufficient conditions for being classified as fruits
of the species musa sapientum. We define a banana, let's
say, as a yellow fruit. And you go to the bin and what do they
look like? Well, some are green, some are brown, some are spotted
and some are yellow. Nonetheless, they're all bananas and we
pick them out as that.
Well, healthcare depends profoundly upon this same kind of
logic. It's not, for instance, the expression of rationality that
makes us human, but our belonging to a kind that is capable of
When a human being is comatose, or mentally ill, we first pick
the individual out as a human being. Then diagnostically, right,
we note the disparity between the characteristics of the afflicted
individual and the paradigmatic features in typical development
in the history of members of the human natural kind. That's
how we come to the judgment that the individual is sick.
And because that individual is a member of the human
natural kind, we also recognize in that individual a value we call
dignity. In recognition of that worth, we have established the healing
professions as our moral response to fellow humans suffering from
injury and disease. The plight of the sick will rarely serve the
purposes, beliefs, desires, interests or expectations of any of us as
individuals. Rather, it's because of the intrinsic value of the
sick, particularly those of us who are here who are healthcare
professionals, have pledged that we will serve.
And I would argue then that intrinsic human dignity is really
in that sense the foundation of healthcare. In a simple way, the
bottom line is that every patient is a somebody and I think we lose
our grip on that notion to our common peril.
That's the end of my brief, formal comments and
I'll be happy to take questions.
CHAIRMAN PELLEGRINO: Thank you very much, Dan. Any indications
of who would like to open the discussion?
DR. SCHAUB: I've got a question about the intrinsic
dignity you cited and also a question about the acquired dignities.
How do we know that something belongs to or is a member of a natural
kind if it is not manifesting the species-typical capacities of
that kind? So human beings seem to be rather different from diamonds
on this score, and in the paper you speak about diamonds, a stone
that was soft and dull rather than hard and brilliant could not
be a diamond.
But I take it that human beings may be human beings without
speech and reason and still be human beings possessed of intrinsic
dignity. But it seems that we stray farther from the nature that is
the ground of our dignity than other beings do and that raises some
serious questions about particular classes of human beings.
The other question I had is about the attributed dignities
and I'm not certain about this category. As you explained it,
these refer to non-intrinsic, but also non-instrumental values. But if
we say that somebody is behaving in an undignified manner, don't we
mean that he's demeaning the highest aspects of his human nature,
those very species' typical capacities that characterize our
natural kind? So we say it's undignified for an adult to behave
like a child or like a dumb animal.
Even a word like dignitary, it seems to me, which might
seem to be more along the lines of a purely conventional usage, but
even that word points to our nature as political beings and thus, to
our capacities for speech and reason.
So these judgments are not egalitarian. In fact, they're meritocratic
or aristocratic. Nonetheless, it seems to me that they are based
on the same capacities that are said to be the source of humanity's
intrinsic dignity. So I wonder if these categories are somewhat
closer together than you suggest and it seems to me it would be
welcome to us if they were closer together because we've been
struggling with these different understandings of dignity and the
possible opposition between an egalitarian understanding and a more
DR. SULMASY: Terrific questions. Thanks. The first is
sort of more the epistemology of how you tell a kind, right? And it
is, in some sense, a different kind of a logic than again saying sort
of the necessary and sufficient conditions that one would have for
membership within a class.
But we're pretty good at it as human beings. I mean
this question is put to me sort of what do I do? Well, I walk out into
the forest and I see a tree, right? And I'm not stupid. I walk
another few feet and I see another tree. And then I see a third tree
and they all seem to have characteristics that put them together that
are different from the other trees that I see around me. And from
those examples, those paradigmatic examples, I then am able to sort of
say to what extent does this individual fall under that extension?
There are obviously going to be boundary categories within this,
but another example would be, for instance, people have asked me
well, is a hydatidiform mole not a human being, it's got the
same genes, right? But I would say that if you go to a standard
textbook of medicine and go back to sort of Aristotelian sort of
questions, there's been a substantial change. That's another
kind of — it's another substance. It's another —
it might have the same genes, but it's a different thing and
not just a class, but a whole different thing.
Pediatricians will sometimes have this problem when
they're looking at an individual, but I think they begin by saying
this is an individual member of the human natural kind, not another
species. It depends on science, so we do a lot of scientific study
that refines our understanding of the typical — of the natural history
and typical features that are part of the kind. But it is not in the
end the immediate expression of all of those activities that allows us
to make the judgment whether this is a member of the kind or not.
Second, your sets of questions about attributed and
intrinsic dignity, I think, are very important. And the paper you got,
and I apologize for this. I was hoping there would be proof pages of a
chapter that's a later development of that in another book
that's coming out and I gave it to Dan, at least the word draft of
it, the manuscript draft. So maybe the Council would want to see it.
I make — and I try to do this quickly here, because of these
sorts of considerations which I think are real, a set of three distinctions
between intrinsic, attributed and then what I've called derivative
senses of dignity. I think a lot of what you were talking about
was in terms of derivative senses of the word, uses of the word
dignity in which — and I think perhaps, for instance, going
back reading the transcript, some of Jim Childress's talk last
time was really talking about how, for instance, Dr. Kass, I think,
often uses an attributed sense, the sort of derivative sense. How
well is this individual actually comporting, behaving in light of
the kind of thing he or she is as a human being and the excellences
that are part of what it means to be that kind of a thing? And
I think that in some sense is — may be a different class because
it's not one hundred percent intrinsic in that ultimately the
value goes back to what kind of a thing it is, but it's certainly
not purely attributed either.
And then within the attributed class of values, remember
that I'm talking about two classes of attributed values,
instrumental and noninstrumental. So I think there can be some
non-instrumental, attributed values, sport, humor, things like that,
and some that are purely instrumental and attributive. And it's a
long-winded answer and we could probably talk at greater length about
it, but that's maybe at least for your benefit and I don't know
if anybody else's, some further clarification.
CHAIRMAN PELLEGRINO: I have Dresser, Kass, Lawler and Carson,
in that order.
PROF. DRESSER: So again, I am going to push some
specifics. I guess the first question is under your approach, all
human beings have intrinsic dignity, but that doesn't mean that
treating all human beings with dignity means exactly the same kind of
treatment. So the next step for a physician or for us in bioethics
thinking about what's right and wrong in terms of how we regard all
these human beings with dignity, are there systematic ways of
approaching that or is it just sort of casuistic? How do you think
about those issues?
DR. SULMASY: Another good question. I think that
particularly in the setting of healthcare, I did a little of this in
the paper, that there's no doubt that one of the things that
illness and injury do is to assault our attributed sense of dignity.
There's no question about it. People who are very sick and
particularly the dying are robbed of their station in life. They are
— they lose control. They appear differently to others and are valued
differently by society. All of these things happen to them and illness
brings those things upon them.
But I think one of the fundamental questions is, is that all there is
to their value? Because I think medicine proceeds this way. It
says that because I recognize the intrinsic value of the person,
then I have a duty to build up, to the extent that it's possible,
the attributed values, the attributed dignity of that person to
the extent I can. That's largely what I do.
I think though that if that's the basis for it, then, in fact, a
limit on what I can do is not do anything that would, in fact, eliminate
or contradict the basis upon which I have decided I have a duty
to do this. And that would be anything that we would consider a
violation of the intrinsic value of the person. And so it's
in my view that lots of our negative norms, don't sell yourself
into slavery, do not kill, those kinds of negative norms, are associated
with a recognition of the intrinsic value of the person and lots
of our other kinds of duties of beneficence, if you will, are associated
with the attributed dignities of the person and doing what we can
when, particularly in health care, illness and injury raise questions,
even for the person, about their value and certainly mount assaults
that are palpable on their attributed sense of dignity.
PROF. DRESSER: Would you have anything to say about
so-called enhancement uses of medicine and how that relates to
DR. SULMASY: It is another interesting question.
I haven't fully developed that aspect of it yet, but I think
that certainly this will have that kind of an impact. Are there
questions about what we're trying to do that change, if you
will, the kind of thing that we are, what we're attempting to
do and is that different from going after a beneficent duty to help
the functioning, the flourishing of something as the kind of thing
that it is? But I haven't really fully developed that and I
think it might be, though, a fruitful way of looking at some of
DR. KASS: Thank you and thanks very much for the effort to
try to clarify these things.
I'm going to try to follow where Diana Schaub went earlier.
I'm grateful that the new development of thought now has a category
of things which are not simply attributed as, let us say, the human
virtues might, in fact, be. But it's not clear that the relation
is best expressed in terms of intrinsic versus derivative. Derivative,
yes, in the sense that if there is no human life which is respected,
the other things are not possible, but one might argue that —
in fact, Alfonso gave us the text on this earlier, that in order
of logic, it is actuality which precedes potentiality and if, as
you say, the dignity of the human being has the species-typical
capacity for language, rationality, love, free will, moral agency,
creativity, etcetera, then it would seem that there would be greater
dignity of an intrinsic sort once those capacities are, in fact,
fully realized. And that what we — and we might argue as
to whether this particular instance is a realization or a perversion
of those particular capacities, but I don't — I think
that lots of human virtues, one could argue, are not stipulated,
but in fact, discovered as is the awesomeness of the Grand Canyon
and the like.
So I'm not sure that I'm — I think there is — I
wouldn't sort of say intrinsic versus derivative, but I would
say basic and full and then the question is what's the relation
between these two things? And that would be one point.
The second point is your argument is of a special value for
the use to which you put it in the paper which is to say the assisted
suicide and euthanasia question and whether one could ever act in the
name of the intrinsic dignity of the human being by being the agent of
its demise, no matter how merciful or worthy our intentions.
But there are lots of aspects of bioethics, certainly the Beyond
Therapy Report which Rebecca was in a way alluding to, in which
the question is not going into a business or out of business, but
whether we are contributing to what Professor Churchland called
earlier human flourishing or not, whether we are somehow adding
to our worthiness as beings who realize those capacities or not.
And it seems to me that we need in bioethics, sort of both of these
A third question then is how are they related? And one
would like to think that these are not simply the distinction between
the preferences of aristocrats versus the preferences of egalitarians,
but that there's some kind of deep relation between these two
things and I wonder if — I'm winding up with an invitation for you
to speculate on that particular point.
And then second, to press you on the really hard thing at
the end of the paper, to give the other concrete case, what happens at
the end of a life when all of those capacities are lost? And let's
take the hard cases where it's hard to tell whether any of those
capacities are still present. This is certainly still the life that
has lived such a life and still remains, at least bodily speaking, a
member of that kind.
You said it very nicely, I thought, in saying membership in
a kind that has these. And what happens when medicine, this great
institution which is meant to — which rests finally, as you say, on
the fundamental value of human dignity, seems in fact to be not only
not doing any good, but continuing the abased condition, not merely
socially abased, but the condition of a human being who is in all
fundamental respects a kind of mockery of the human being that their
life was. I speak provocatively.
Couldn't one somehow say that medicine has produced a
conundrum for which we don't — for which this insistence on the
intrinsic dignity is — leads us to do great harm to the dignity which
is the human being?
DR. SULMASY: There are points at which the subparts of
subparts of questions probably totalled up to about seven there, but
let me try to answer some of them.
DR. KASS: The paper is quite rich in that way. It really
spurs you on.
DR. SULMASY: Well, thanks. They are all great questions.
Yes, I think that the — I'm happy that I've
developed the thought in advance of this and again, I've handed at
least the manuscript version of the paper for you to take a look at.
I'm not sure that I want to quibble over the name, but I have
recognized through the critiques — useful critiques of others, that
attributed and intrinsic is simply too stark and that there had to be
some other category that is, in fact, the instantiation, the
development, the flourishing of the excellence of the kind of thing
that it is, which depends, in part, on the intrinsic value. If we
wanted to come up with other names for that and derivative still sounds
too small for you, I'd be open to that. Because I think the
important part is the question you're asking about what's the
relationship between those.
In terms of other uses of the work, I think I'm only beginning to
look at some of those sorts of questions and I think you've
spent yourself some more time looking at it in terms of therapy,
enhancement, life extension and I think it will have a value there.
I just don't — at this point, know anything other than
to say that attempts intentionally to change the kind of thing we
are is probably a different category than enhancing or flourishing
or abating or diminishment and that would have moral weight and
we'd need to look more seriously at what that actually meant.
How are they related? Well, once you, I think, accept the
notion of the human being as a natural kind, then we have and
there's a very good book on this by a man named Anthony Lisska who
talks about dispositional predicates, the sense that we have, as a
kind, dispositions. Part of that is to grow and develop through
certain stages of physical development, but they are also our
capacities for moral choice, aesthetic experience, etcetera and that,
in fact, our flourishing as those kinds, may in fact, in some schools
be the point of ethics. Right, that we sort of move to flourish as the
kinds of things that we are.
And so I think that yes, it's the sort of sense that there's
a bedrock grounding, if you will, in the intrinsic value that we
have by being members of the kind, but being members of the kind
means that there is the possibility of flourishing as a member of
that kind. Philippa Foot, for instance, talks about the word "good"
being not a predicative kind of adjective, but one that makes us
need to take into account in some way the kind of thing it is.
So if we talk about an example I sometimes use, a good
bottle of wine, right, well, that can depend. I say sometimes
that's a good bottle of wine for wine from Long Island, right?
But there's a sense that to say the word
"good" we have to have some notion of what kind of thing it
is and what is excellence for that kind and what's the flourishing
of that kind.
To go to your sort of example of the person who has lost all the
capacities, one of the features of the human as a natural kind as
any other biological natural kind is its finitude. And I think
that also human arts, like medicine, have to recognize their own
finitude as well. And so that when we come to the point where an
individual has lost as many of those capacities as we would care
to imagine, I think that in recognition of what kind of thing it
is that we do not have an obligation, this is not a vitalist's
view, I don't — we don't have an obligation to do
everything that would be possible to sustain that life in that stage,
but I do think that our recognition of the intrinsic value does
put a negative norm in place that says we can't take an action in
which we would snuff out that life because that would be again contradictory
to the very basis that I think from which we start our whole ethical
So yes, there's a lot more to be done here. These are
beginnings, these are a couple of papers where I'm moving in this
direction, but I thank you for your questions because I think
they're right in the same realm that I'm trying to think about.
CHAIRMAN PELLEGRINO: Dr. Lawler.
DR. LAWLER: Again, thanks so much for the great
This category of natural kind seems to mean something we
can see with our own eyes that we didn't make ourselves. Right?
But the word natural has a certain ambivalence to it because I want to
think natural in the sense of human nature, biological nature. But
Kant identified this natural kind human being that we can see with our
own eyes, but it's not natural in the sense that we have dignity
and insofar as we transcend nature.
But that actually doesn't seem to be your view. Your
view seems to be we have intrinsic dignity because of capabilities
we've been given by nature. So you seem more of a Thomist than a
Kantian. That's good.
Now in light of our first presentation this morning, you might
have to answer this sort of question, does your understanding of
the intrinsic dignity of the human being require a natural science
different from the natural science of the neuroscientists or the
natural science of the evolutionary biologists or the sociobiologists.
And one other comment that has nothing to do with that
first one, I apologize for shifting. I do think Leon and Diana are
right that you probably should have intrinsic dignity one, and
intrinsic dignity two or something. You have this intrinsic dignity
that comes from these natural capabilities we've been given, but it
also has to be intrinsic dignity in the exercise of those capabilities
in a virtuous way.
And I would add a little bit contrary to them, it's not just
excellence, really, because I'm not sure there is — you
don't say "he dunked the basketball in a dignified way."
That's surely excellence, right. Or "he buried three holes
in a row in a dignified way" or something like that.
Dignity would be the exercise of virtue that's not necessarily
even a human perfection, but living well with adversity, living
well with finitude, living well with responsibilities given to members
of our species and any other species like ours on some other planet,
I don't care about that.
All right, so the connection of identification of dignity
with excellence in terms of intrinsic dignity two seems to me to be
wrong, but I can't correct it in exactly the right way.
I think you have to distinguish between excellence one and
DR. SULMASY: Let me take the first part. Yes, I think
this is not something that comes in opposition to evolution, for
instance. Natural kinds evolve. Biological natural kinds evolve. And
so I have no objection to the incorporation of evolution into my
conception of the human natural kind.
And human natural kinds have brains and all the science that we
do and split brain experiments that I learned about as a Cornell
medical student, I mean they're all wonderful things to do.
We are capable of doing those things as a kind; as a kind that can
understand itself and other parts of nature well, so there's
no sort of opposition to the science. It's simply maybe a suggestion
that the science itself doesn't give us our ethics.
And yes, I'll take the criticism that derivative,
again, may not be as robust a term to capture the sort of sense of
living well as I would have intended it. It sounds probably a little
more pejorative and I'll try to think of another word and I'm
open to suggestions as well.
CHAIRMAN PELLEGRINO: Dr. Carson.
DR. CARSON: Dan, thank you for that. That was wonderful
and it's good to have you here. And Leon already asked my
difficult question, so I have an easy one for you.
Are value and dignity relative or absolute? And let me put
that in context. If you have a diamond, let's say you have the
Hope diamond on the one hand and you have an apple on the other hand,
most people wouldn't have any trouble attributing the appropriate
value. However, if you were the only person in the world, which would
then be most valuable, because the diamond really has no intrinsic
value, but the apple at least you can eat.
DR. SULMASY: I think that there are, in fact, out of this
sense of intrinsic value of things, particularly when we get to human
interactions that we could generate some things that I think are moral
I do think though that there's a sense in which other
things in the world have value independent of me. The existence of
stars, that stars have value other than the fact that I give it to them
or other people have given it to them or that we all together give it
to them, but they have an intrinsic value as does a diamond or an
But there's also something of a hierarchy of these
things and so for a human being I can use an apple for its instrumental
value and in the condition of just being hungry, an apple has
instrumental value for me and I can eat that without denying its
intrinsic value. I think when we get to the level of the human which
has the intrinsic value that we call dignity, that that gives a norm
which is qualitatively different in terms of how we respect the
intrinsic value of the human.
And again, I would add how I would treat the intrinsic
value of an extraterrestrial that I met that had all these capabilities
as a kind. If there were — if we discover some day martians who have
language and love and aesthetic sensibility and reason, I think it
would be wrong ever to, for instance, end the life of such a creature.
DR. ROWLEY: Dr. Rowley?
DR. ROWLEY: This is an area in which I'm not even
quite an amateur, but I was interested in your explanations in the
beginning of the evolution of the context or the implications of the
word dignity and how individuals through time and societies have viewed
So I assume that you would be accepting of the fact that we are
still in the process of evolution, at least some aspects of our
understanding of dignity, and that as we understand more about neuroscience,
our notions of what may be either functions that allow dignity or
enhance dignity are going to be far — have far greater understanding
of the influence of these neurosystems on — at least some
aspect of dignity and I don't want to get into whether it's
going to be derivative dignity or intrinsic.
But so (a) it seems to me dignity is still an evolving concept.
Second, to the extent that you use the word flourishing, does society,
and this is the same question I asked Pat, does society have a responsibility
to see that every human being in the society is allowed to flourish
and what are the political and social and legal implications and
ethical implications if we do, as a society, have an obligation
to see that every human being flourishes?
DR. SULMASY: Again, all great questions. I'm
grateful for those as well. Yes, the uses of the word have changed
over time. I'm not sure in reading it myself and I don't
know if Professor Schulman would agree with this or not, but I'm
not sure it's always simply been an evolution. I think people
have used it in different ways in different philosophical systems,
and so all I was trying to do was to give an array of some of the
ways in which that's been done and to try to classify some of
those uses in a way that might be helpful to understanding different
ways in which the word has been used that might particularly have
use in bioethics. Because I think all those different conceptions
have occurred historically and all those different conceptions occur
today. For instance, in the assisted suicide debate, the bill that
legalizes it in Oregon as the Death With Dignity Act, the reason
people oppose it is they say it's an affront to human dignity.
My view is they're using it in intrinsic and attributed senses
and that's part of how we can understand why there's a clash
And will increasing knowledge help us? Yes. I think, I'm
less sanguine that our knowledge of neural networks will help us
than I am with good, philosophical analysis, but I think that we
can take the knowledge that we get from the sciences and the physical
sciences, biological sciences and the human sciences and continue
to work on our conceptions of this.
Second, in terms of human flourishing in society, we are as
a kind social, inherently social. and the most — the deepest sort of
sense of the common good we could have I think is one in which the
flourishing of the whole, in part, instantiates my flourishing in a
very rich, deep sense of our common good. And yes, I think that these
ideas feed very much into political philosophy and there are people who
are doing serious work in this. There's a guy named Rasmussen
who's working on this in political philosophy. Thomas Hurka's
book on perfectionism, is a philosopher who is working on this
conception of natural kinds and perfectionism in terms of political
philosophy. There's a guy named Steven Wall who is doing work on
it in terms of political philosophy as well.
So yes, I think that for human beings, for us to flourish, as the kinds
of things that we are, being as we are a social kind, that our flourishing
has to be within a society.
CHAIRMAN PELLEGRINO: Dr. Meilaender.
PROF. MEILAENDER: I also want to thank you very much for a
very stimulating response to our invitation.
I want to return to the questions that Diana and Leon were raising,
although maybe a tug in a slightly different direction which will
not come completely as a surprise to everyone. And whether I'm
really going to make sense or not, I'm not sure, but let me
Very nice, and I think on the whole it works very well, the
argument worked out in which intrinsic dignity is really a
characteristic of the kind of thing that human beings are. You pick
out that kind by pointing to certain kinds of capacities that are
characteristic of the species, but the dignity is ascribed to members
of the kind. But then you've developed the derivative language to
try to deal with the fact that it's sort of troubling and gets us
into some hard questions that some individual members of the kind seem
to display those typical characteristics much more fully than others.
I think I've got the problem right.
Interestingly, you turn to the word derivative to do that.
Leon, in kind of trying to think aloud about what didn't seem to
work for him about that, floated basic versus full, which of course,
turns — you begin with the kind and derive something from that.
He's got something different going and if we add the word humanity,
we've got basic versus full humanity and I suspect maybe that's
a formulation you're not quite happy with.
Now I want to try to just shove you in a certain direction
that you might not want to go and that maybe you shouldn't go,
actually. I'm actually not sure in my own mind about this, but I
just want to think about it because you want to sort this out as an
entirely philosophical theory and if that could really work I'd be
tickled to death. But I'm not sure about it.
And Kierkegaard has a really nice little story at one point about
two painters and the one painter says, he's a great artist and
he's such a great practitioner of his art that he's traveled
all over the world, but he's never found a human face so lovely
that really seemed worthy of his art. He's never painted it.
And the other painter says well, you know, I just stay right where
I am and Kierkegaard says maybe because he brings a certain something
with him, he's never found a face that wasn't worth painting
because he carried a certain something along with him.
Now what I'm wondering is whether the decision whether we
should kind of start with intrinsic and then work out some kind
of derivative language or whether it's basic and full, whether
that's something that can be entirely settled on the basis of
the kind of arguments that you're making, which are very nice.
Or whether, you know, you've got to bring a certain something
with you. You're either going to see that full dignity in every
human being whether or not they display those species-typical characteristics,
or you're going to think that although there's a certain
kind of basic humanity there that we have to honor, nevertheless,
it wouldn't be a face quite worth painting sort of.
And I'm not sure that that's settled by a set of
arguments so much as it is by something you carry along with you and
I've left it as vague as Kirkegaard leaves it. I don't know,
if that makes any sense at all to you, I'd be interested in hearing
your comment on it.
DR. SULMASY: No, I can see where you're
going with it and I think it would be interesting to probe further.
I guess the derivative language and the — neither the derivative
nor the basic and full is sort of satisfactory to me and partly
the basic/full I think from some of the reasons you gave. It may
be that this sort of — it has to do with the sort of flowering,
the flourishing of the individual as the kind of thing that it is,
recognizing also though our — frankly within this that our
finitude that I talked about further is tri-fold. It's not
simply physical finitude that characterizes individual members of
the human natural kind, but we're also and we have to recognize
this always, finite intellectually, we make mistakes, and we're
finite morally. We fail to see some of those things, like seeing
the value that's there in the individual.
It becomes another question whether philosophy alone will
be able to always get you to be able to see that or see it in a better
light or whether one needs the something other that you're
suggesting and I'll probably leave the question back there again
where you left it. But I think it's a different way of framing
within my structure some of your questions which I think are important.
CHAIRMAN PELLEGRINO: Dr. Hurlbut.
DR. HURLBUT: I don't know quite where to go after that
I mean I actually would like to ask you this question, but
I'm not going to. I'd like to ask you to distinguish between
dispositional predicates, character and properties which I think
there's a sense in which they blend upwards into your — but I
won't ask you that.
Instead, what I want to ask you about is I want to return
to the comment that Mike Gazzaniga made at the end of the previous
session where he said that there is —if I understood it right, Mike,
you said basically that our moral sense or our personal dignity were
irrelevant categories if you were the last and only person left on the
Could you maybe rephrase that or did I get that okay?
I immediately feel uneasy about a statement like that and because I
think to myself there are moral categories that relate to human
dignity that are just somehow inside my being that even if I were
the only person or even if I did something that no one ever saw,
that I could do acts of self degradation or I could do acts of degradation
against the backdrop of the cosmos that would, in fact, both vitiate
my nature and do violence against the larger order of things.
So I just wanted to in the larger context of your
presentation, let me ask you to reflect on that a little bit and
specifically, as I was reading your paper I was thinking this category
of dignity with a capital D that you apply only to human beings, as far
as I could sense, I was thinking about it. Is there another category
we could apply that to and it's a bit of a leap, but to the cosmic
It's funny because we all know that we are what we are within
a relationship to the whole and there seems to be something about
the whole that while it doesn't in any way erode the individual
human being, not more than just the context of dignity, but as an
intrinsic quality of goodness. And in doing so, you might reflect
a little bit on this category I mentioned of self-degradation and
the relationship to suffering.
DR. SULMASY: The last part came out, there's suffering
too. That's a third part.
DR. HURLBUT: Yes, the internal.
DR. SULMASY: But let me try to take some of these
questions. The first part, yes. I would disagree with Dr.
Gazzaniga's view that ethical terms and categories only arise
intersubjectively and are intersubjective constructions and if there
were only one person left on the earth, I still think that person would
have moral responsibilities, duties and among those would be
self-regarding acts. So the question of suicide would arise. The
question of how I do treat the rest of the physical universe does arise
and I think those are moral questions.
There's no doubt that such a person living alone would
have by virtue of the physical conditions there flourishing as a human
being impaired because there's no one else around. But it
doesn't mean that all morality would cease under that circumstance
or that that person wouldn't have intrinsic dignity and have duties
Regarding the value of the cosmos as a whole, that's actually
where I got this idea to begin with. I mean sometimes, I edit Theoretical
Medicine and Bioethics and one of the problems I find with a
lot of the discourse in bioethics is that a lot of it has become
so political that people aren't reading any philosophy at all
and that it's valuable to read fairly broadly. So I got the
idea from Holmes Rolston III who is an environmental ethicist who
is trying to argue about why we do have duties towards things other
than human beings and things do have value other than our uses for
them. And so yes, I do believe that other things have intrinsic
But I do think that that's not completely homogenous,
that there's a scale to that value as well and that any kind that
would be capable of the kinds of things that human beings are capable
of as a kind, would have this kind of intrinsic value that I'm
labeling dignity with a capital D.
As I've said, that would include extraterrestrials, if
we found them, that had that. Those kinds of things.
Now, the question of the relationship of these — this conception
to suffering. Yes, I think that's a very important part of
this whole — of medical ethics, of philosophy of medicine
and actually of natural kinds as well. And I have a very —
again, a pretty different take on what suffering means than has
been in a lot of the literature as well, and related to the idea
of natural kinds. I was saying before, in response to Professor
Meilaender, that in fact, our finitude is at least tri-fold, right,
that we are finite physically, finite intellectually, and finite
morally. And it's the apprehension of our finitude that I think
is the substrate of our suffering.
So pain hurts, right, but the pain of arthritis does not
really become suffering until the person can't open the jar,
right? It's the sort of sense of recognizing their limits. And in
its own little way, when I hit 45 and I had to get my reading glasses
for the first time, that, in some ways, reminds me of my finitude.
There's a way in which every wave of nausea, every drop of blood
that a patient experiences in some ways reminds them of their ultimate
finitude, causes them, in fact, to come to grips with the fact that
they can't do the things they used to be able to do as agents in
the world and that that's an occasion of suffering for them.
But likewise, there are lots of other occasions of
suffering that are caused by our moral finitude and our intellectual
finitude. So I think it relates to the idea of natural kinds as well.
CHAIRMAN PELLEGRINO: Yes, please.
DR. HURLBUT: Holmes Rolston, his central theme, as far as
I read him is that the cosmic whole that has an intrinsic dignity also
has an in-built incompleteness or imperfection that calls forth from
its higher order of beings a kind of willingness to enter into what he
calls Kenosis, a self-emptying, a self-giving, a self-donation, a kind
of willingness to participate in suffering for the sake of the whole.
Is that consistent with what —
DR. SULMASY: Yes. I think there might be a sense of
stewardship, right, that we could say is part of our responsibility,
being the kind of things that we are that can recognize the value of
CHAIRMAN PELLEGRINO: George, McHugh and Alfonso.
PROF. GEORGE: Dan, I really admired the rigor and
precision that you brought to discussion of a difficult ethical
concept. You must have had a good teacher.
DR. SULMASY: Several of them.
PROF. GEORGE: Yes. At the last meeting, when we were
discussing Dr. Schulman's excellent introductory paper, I advanced
the argument that whatever is to be said about the concept of human
dignity, we have a national commitment in the United States to a
certain conception of human dignity and that national commitment is
expressed in the great self-evident truth as it labels itself of the
Declaration of Independence.
I think that's really quite a radical, an amazing proposition,
because among its implications, is the idea that as between magnificent
exemplars of humanity, the brilliant Albert Einstein; the athletically
magnificent Michael Jordan, on the one hand, and let's say a
severely debilitated, retarded person on the other hand, there is
a profound equality that despite the manifest inequalities of intelligence,
strength, ability — there is at the most fundamental level
an equality such that we would, if we're true to our national
commitment, never entertain the thought that we would be justified
in taking the life, even of a severely retarded person, severely
debilitated person to harvest organs, heart or liver, to save the
life of a magnificent human being like Albert Einstein or Michael
Jordan, we just wouldn't go there, we just wouldn't do that.
And so I ask, is that commitment to that particular
conception, that radical conception of human equality and dignity, with
its implications, a noble myth, something we're committed to
because of the social consequences of adopting any alternative view,
living in a world where we would countenance such a thing as taking one
life to spare others or save others?
Is it a noble myth or is it what it claims it is on its own terms,
as expressed in the Declaration. And that is a truth. Is it really
true that that severely retarded, debilitated person is the equal
at the most fundamental level, in dignity, of Michael Jordan and
DR. SULMASY: I think if you take the implications of my
paper seriously, the answer is yes, that that is actually true.
Whether we behave in a manner consistent with that is obviously another
The real ethics and that ends up with the sort of "as if"
constructions of morality, you know — let's pretend this
noble myth, as you say it was true, because that's the best
way we can solve it, — in the end, I think, becomes a very
dangerous way to construct a moral universe in a society. Let's
make believe this is true, even though, wink-wink, we all know actually
what isn't, that we've just all made it up.
And so I believe that this is part of what Kant did, was to democratize
this concept of dignity, to make it something that is inalienable,
that doesn't admit of degrees, and that this is, in my theory,
Another quote that's appropriate here is Simone Weil
says that what's most important in a human being is the impersonal
in him, which, of course, comes as a shock to most Americans when we
begin to think about a quote like that.
But I think it's to the point of what you're suggesting.
It's not what makes us unique and individualistic, but what
we most fundamentally have in common, that we are members of the
same natural kind, that is the fundamental basis of dignity and
I believe the fundamental bedrock of a moral system.
CHAIRMAN PELLEGRINO: Dr. McHugh.
DR. MCHUGH: I too, Dan, enjoyed your talk very much. I do
feel that I'm scrambling to keep up with you in these abstract
realms in this world.
And I want to follow along a little bit, I think, with what
Gil Meilaender was asking you and you and me, back where we really
belong. We're in the process of trying to turn medical students
into doctors. A difficult task, but a wonderful one. And it's a
process in which we're trying to form their character, as well as
enhance their knowledge.
This is a bit of a prologue to my question and in that process, I discovered
— I was taught really, by a great surgeon, how to think about
disorders and illnesses, the blemishes on those bananas. And he
taught me, and he changed surgery in that direction that we should
be thinking of disorders differently than it seemed that was being
taught in medical schools before, that diseases weren't entities,
but they were human life under altered circumstances, altered physical
circumstances, altered social circumstances, altered environmental
circumstances and our job was to try to fit that — those circumstances
better so that their life could flourish.
The reason this was such a telling idea that I got from Francis
Moore was that it then made it clear to me, one, why I should be
very, very interested in studying the sciences that were emerging
around — I mean work like Janet Rowley's work comes to
life when gee, I've got to understand what Janet is doing because
she's showing us in what way life changes with these interesting
genetic and molecular changes that make sense of the disease now,
as a process; and makes sense also about our growing capacity to
It did that on the one hand, and on the other hand, it also told
me, gee, you know, I was supposed to be going to try to benefit
that life by putting those circumstances back together. But that's
the background to it. So it had a very practical function in developing
this idea, again, which Pat Churchland talked about, namely demonstrating
processes and thinking that would make us more effective, having
the more power of character and relating to what doctors relate
to, namely, the individual in that situation.
So, with all of that, I want to know whether you see similar practical
advantages, in the character formation of the young doctors that
you're teaching and try to bring along, by asking them to think
of this idea of natural kinds, rather than individuals living a
life in which disease and disorder has altered their process and
Does it have — you mentioned there were negative things
that it got you to do. Are there positive things that you'd
say now doctors should really learn how to do this and think about
this so that they will encounter their patient in the way the patient
really believes benefit is built which is, you know, which is a
linkage between two people, people who are themselves expecting
things from each other?
This is a Council on Bioethics. This is a test as to whether
bioethics does us any damn good or not and hence my question ultimately,
do we have more practical things to think because of what you're
telling us rather than what Francis Moore said, think of disorder
as life under altered circumstances?
DR. SULMASY: I don't think those are incompatible
notions at all. I mean I may be approaching it from a philosophical
point of view. I haven't mentioned natural kinds once in a lecture
I give to the medical students,
But well — it's because, no, no, because it obviously
isn't going to work very well in that setting.
I will, since you like stories, tell you from my own days as a Cornell
medical student, of a time I was asked, as a sub-intern, to transfer
a demented patient from the room the patient was in, to another
room that had other demented patients in it. And this was the third
time within a week the patient had been transferred rooms because
the resident wanted, under those circumstances, to just keep the
demented people all hoarded together and keep them away from the
And when I objected, at this point, that this was an affront to,
I thought, to that person's dignity, I was told that, one, what
are you worried about? She's got two neurons held together
by a treponeme for a brain. And I refused to do it, under those
circumstances. And doing that as a medical student, getting your
letters of recommendation is not an easy thing to do. It was on
the belief which I already had at that point, that that person,
as a human being had dignity and that my job, even as a student
as I recognized it, was to care for the dignity of that individual.
And fortunately, in my stand, it had an effect. The person
actually thanked me later, said you're right. I'm getting too
cynical. I'm sorry about this, and I need to be aware of the
dignity of patients.
So I think the concept of dignity is extraordinarily important
and I define vulnerability (and people who are demented, for instance,
are among the most vulnerable) as those whose dignity is at risk
that it will not be recognized.
And I think students can understand that, and they have to
be brought typically by example to understand that that individual that
they're treating, whether they're demented, whether they're
homeless, has dignity and that that's why they're serving
them. And if they need to be convinced by natural kinds, most of them
are convinced more by the stories.
CHAIRMAN PELLEGRINO: Gómez-Lobo.
DR. GÓMEZ-LOBO: I don't think I need to
be convinced by natural kinds, but I do have a question about natural
kinds and it's this, that when the whole idea was introduced
and defended by someone like Kripke, etcetera,that there was his
concentration on the molecular level, for instance, the quantification
of water as a natural kind has to do with the fact that if something
has a molecular structure of water then it is water.
Now the question is this, do you think there's any hope
that we're going to be able to identify let's say a necessary
and sufficient set of genes, genetic material for human beings? Of
course, this is terribly important for Bill Hurlbut and for all of us
because of the altered nuclear transfer issue.
DR. SULMASY: Yes. First, I think that the development
of natural kinds has gone a lot since Kripke, whereas somebody like
Wiggins is the person that I think is, in Sameness and Substance,
has really got the best sort of hold on this. And even people in
the area of bioethics, Baruch Brody had an early book on natural
kinds as well before he started doing ethics.
And so I think it is something that's gone way past
simply molecules at this point.
The question of whether or not there will be a necessary and sufficient
set of genetic properties that will define the human genome, I say
no. And I think actually, you and I may have had a little bit of
a conversation about this a few years ago, but I think that one
of the best books on this topic of sort of genetic reductionism
is Lenny Moss's What Genes Can't Do. So if people
haven't read it, it's a great book. It sort of says, as
one person has put it, DNA didn't invent life. Life invented
DNA. That it's probably better thought of as a part of an animal,
as it is as the — if you will — physical correlate
of the soul.
I'll leave it there. There's a much longer
CHAIRMAN PELLEGRINO: Thank you very much, Dan, and thank you
all for your comments.
We've stolen about 15 minutes. Let's return at
2:15 for this afternoon's session, so lunch won't be curtailed.
(Whereupon, at 12:33 p.m., the meeting was
recessed, to reconvene at 2:15 p.m.)
SESSION 3: MORAL OBLIGATIONS TO
CHAIRMAN PELLEGRINO: What we hope to do in this
session — it's an open one, and we can use it as we see
best — is to get your responses to what you have, the material
you have, and what has been done thus far on this question of children
and the ethical issues related to our responsibilities to children,
get your reactions to what we have, get your reactions to the readings
that were prepared by Eric Cohen from the literature, do they pose
questions that you consider to be important that we ought to pursue,
what are those questions, how should we pursue them, how far should
we go, where are we, really a general discussion on questions on
As you know, we decided to take a look at this as a bookend
to the last large report you gave on aging. And it may or may not be a
wise thing to do. The dignity issue, as you know, will move along
because we have decided we will do an anthology. We are very, very
thankful to many of you who have agreed that you would do a paper or
commentary. And that would be the best way we think to embrace the
breadth of that concept, as you heard this morning. It has many
We must begin, rather, on the question of the
children's issues and children's ethics, what have we left
out? What should we do? You have several more coming this afternoon
and tomorrow on specific issues.
I'm talking because I don't see any red lights
going on. And that's one way to change my verbosity into quiet
silence. I always like to observe the advice of the Talmud, which says
that silence is a fence around wisdom. If you don't open your
mouth, they won't know how much you don't know. Talmud is a
very wise book, and I've made use of it many times.
How about a red light here? Thank you very much.
DR. KASS: If you are looking for a fool, I will
CHAIRMAN PELLEGRINO: I'm looking for an interpretation
of the Talmud, please.
DR. KASS: First let me say that I welcome at least this
preliminary exploration of the subject of children. I think it, at
least for me, remains to be seen what piece of this, if any, is worth
We have in previous efforts touched upon the subject of
children, especially in the, say, "Beyond Therapy" report,
where the question of better children, of course, raised questions of
what is a child and what is better. We at least touched on them,
though we didn't do much more than that.
I thought that, at least some of the beginning discussions
of the last meeting from our expert presenters, raised some interesting
questions worthy of our attention, if not further study.
I also like the fact that we are beginning in this session
with the questions that Eric Cohen has invited us to think about. I
mean, before getting down to the question of what you should think
about, genetic screening of newborns or experimentation on children, it
would be useful to try to sort out, as Eric puts it right in the very
beginning, what kind of a person or a human being is a child and what
follows from that account as to what it is that we owe children, both
those that are our own and those that are members of our community and
ultimately to children around the world. It's a subject dear to
Janet's heart and not only to Janet, around the table.
I guess, I mean, I would be presumptuous, I think, to try to say
what I think a child is, though I would maybe open up with a couple
of observations that I think shouldn't be lost sight of. A
child is not only an immature being, but compared to the young of
other species, a remarkably immature being in that, as Adolf Portman
pointed out, the human animal is the only animal that is born very
premature andhe coined this term of the "social womb"
for the first year of life, in which the other mammals are born
and walk almost immediately. These things have to be learned.
And they are learned in the social context.
The first thing I think to notice is that this immature
being stems from and is enmeshed in a series of very particular
relations, both of natural origins but also of cultural and social
relations. Often these are the same, not always, as the case of
adoption, I would point out. And somehow attending to those primary
sort of elementary facts is a place to start.
To say that a child is an incomplete being, especially incomplete being,
means that what it is and becomes depends largely on others. I
mean, to be sure, nature contributes but whether a child gets to
realize any of these possibilities depends upon there being a nurturing
environment and that people take responsibilities for it to begin
This leads to a peculiarity. Bill May, I think, has spoken beautifully
on this subject. On the one hand, a child is supposed to be, by
virtue of its being here and being ours, the recipient of unconditional
love. Mother love is supposed to be like that. Fathers may have
to learn it. But that's the expectation, that the child is
loved for who he or she is right here and now.
Yet, almost everything that the parents do with respect to the child
is to coax it and encourage it to be different. On the one hand,
you're absolutely loveable here and now, which means that you
somehow warrant this kind of unconditional love. And, yet, everything
that we do to you is to say become somewhat other than you now are,
which is to say grow up.
And one of the things that one is — that the trick is somehow
to be the coach or the teacher of the process of growing up without
disparaging or treating as merely instrumental to some later end
the very goodness of the being of the creature who is here. Easy
to say, hard to do. Lots of people do it, on the whole not bad,
and some people have a great deal of trouble.
Only one other comment. It strikes me as odd in the
bioethics literature to lump children in with vulnerable populations as
if that is somehow their defining characteristic. They are vulnerable,
to be sure, but they are not vulnerable the way the prisoners are
vulnerable or for the same reason. Their vulnerability consists, in
part, because of this special kind of immaturity and the special kind
of relations that they have and the special obligations to that kind of
not mere vulnerability but to their possibility. It's the
unrealized possibility as well as the weakness and dependence that seem
to be terribly important when you think about them.
And if you see them merely as weak and vulnerable and at
our mercy, one doesn't see the positive obligations to shape, to
form, to encourage, to develop, including — and this will come up
maybe in the session that we have next — to shape their desires and
their longings, not just the intellectual skills, the whole question of
helping them grow up so that they can somehow flourish and exhibit what
Dan Sulmasy called derivative dignities of the human person.
So that would be a long-winded start. And if speaking a long
time proves one's lack of wisdom, I have served your purpose.
CHAIRMAN PELLEGRINO: It was a good choice of words, no
matter what. Thank you very much, Leon.
Opening up the issue. Please?
DR. ROWLEY: Well, I will continue on. And, as Leon was
speaking, I thought that describing children as incomplete — and then
he used the word "immature" or "maturity." I think
that's a better way. You have a child whose functions even are
partly formed but not completely formed, and they will mature.
So I look on parents as not so much changing the child but
helping to shape that pattern of maturity. And one does that both in
the physical sense in terms of helping children to learn to walk and
talk and other functions, but then also as children get older, trying
to provide them with the kind of intellectual and ethical environment
in which they learn to be the best that one thinks of as all of the
My concern and the thing I keep pushing at is that this is
the ideal and that our society, the American society, and other
societies as well fall far short of that. And in many respects, some
families do. They do that for lots of complex reasons: Single
mothers, abusive parents, abusive adults other than parents.
And I don't see how one can be dealing with ethics and
bioethics, particularly with regard to children, without saying that
there are certain populations — and here I would characterize children
and infants as vulnerable — that society really has to step in and
provide resources and caring and nurturing where parents, for a whole
variety of reasons, are unable to do that. I think we just shirk that
And, of course, it's exemplified in the news today, in
today's papers, that the budget has been passed, the budget
includes cuts. And who are those who are most affected by those cuts?
The poor and the elderly; whereas, we're about to then embark on
making permanent tax cuts for the top one percent wealthiest in our
country. I think that is absolutely unconscionable.
If somebody — and this Council is one potential body —
doesn't point out the immorality of the political actions going on
in this city, I think we have shirked our duty.
CHAIRMAN PELLEGRINO: Thank you very much.
PROF. DRESSER: Thank you.
I don't want to put a damper on a wide-ranging discussion, but I
have a series of questions I wrote down as I was reading this that,
at least I am confused and wondering about and, might help the discussion
or help me.
So we need to construct a framework for bioethical
analysis. Why this topic? What about this topic is pertinent to
bioethics? What can bioethics analysis contribute? What is the proper
approach or analysis? What literature and approaches should we adopt?
As I was just reading this and the other materials for
today, I was struggling with that. And I know we want to go from the
general to the specific, but going from specific sometimes helps us
think about general. And so I thought I would throw those out.
CHAIRMAN PELLEGRINO: Thank you.
PROF. MEILAENDER: Yes. I am not sure how what I want to
say relates to anything that has been said. I only know that I have
always thought growing up was overrated, Leon.
PROF. MEILAENDER: But I want to start from these readings
that Eric so nicely collected for us because I do think that they make
a nice point about vulnerability, though it's not the child,
actually, who is vulnerable in the readings.
If you start from the Tolstoy reading, what Levin feels is a new
and distressing sense of fear. It was the consciousness of another
vulnerable region. That is to say, to have a child, unless there's
something wrong with you — and, of course, alas, there are
people with whom there is something wrong in that way, but to have
a child is to become vulnerable. It's the parent who is vulnerable.
You can now be hurt in a way that you could not be hurt before.
Your happiness is bound up with the child's happiness.
And the most natural reaction to that and in some ways an appropriate
reaction — and this gets to one of Leon's issues that
he raised. In some ways an appropriate reaction but also a dangerous
reaction is to try to be the guarantor of the child's happiness
and well-being, to see yourself simply as a protector, developer,
and so forth.
Now, that's a natural reaction. It's good in some ways
because the child does need protection in certain respects. It's
a natural reaction that's dangerous in other ways because it's
not just a response to the child's needs. It's in response
to my own vulnerability now.
I then learned to think of myself as the kind of possessor of
this other person's future. That's where the Gilead
reading is so nice, the narrator reflecting on this poor guy Abraham,
who has to sacrifice both of his sons, realizes that any father
must finally give his child up to the wilderness, I mean.
So yes, there are responsibilities. Yes, the child has
needs. But we also react to our own vulnerabilities. And I think that
that is not irrelevant to some of the bioethical issues, Rebecca, that
you raise. We won't think these things through carefully if we
think only of the child as vulnerable or incomplete or immature or
whatever the best word is. We have to understand the distortions that
can enter into the way we treat children when we don't realize that
we're not the guarantors of their future.
So, to me, the readings, though not, of course, bioethical
in any ordinary sense of the term, raise some very important questions
about who is really vulnerable here and what the effects of that are on
the way we relate to our children.
CHAIRMAN PELLEGRINO: Thank you, Gil.
As the father of seven children, I recognize this question of
parental vulnerability with a certain degree of acuteness. But
we'll talk more about that later.
Are there other comments on this question? I'll open
it up. Vulnerability of a child and the — I'd like you to think
PROF. GEORGE: Yes. I just don't want my friend Dr.
Rowley's comments to go unchallenged. I don't think we should
conclude, at least in advance of hearing evidence and analysis, that
funding cuts in programs that are designed for children or other worthy
recipients are immoral or that tax cutting is immoral.
I think, rather, if we are to make such judgments and if we
as a Council were to be invited to make those sorts of judgments, we
should have before us critics and supporters of programs that are in
line for cuts and competent economists on the competing sides who are
prepared to debate before us the question of the impact of tax cuts,
making the current tax cuts permanent, for economic growth overall and
for the welfare of people across the economic spectrum.
I don't want to prejudge that question because I'm
not myself an economist. And I'm not competent to judge and I
wouldn't want to try to reach any judgment in advance of hearing
the evidence and arguments on the competing sides. But I would
certainly resist declaring these proposals to be immoral before hearing
that evidence and those arguments, particularly as a Council.
DR. ROWLEY: Well, I would certainly
support that. And I think part of my impassioned plea was that
as we look at this issue — and I guess part of this is a question
of if one takes up the issue, that, in fact, a component of an adequate
assessment of this whole area would include just what Robby is proposing.
And I would support that wholeheartedly.
CHAIRMAN PELLEGRINO: I think we are moving into the realm
of what the obligations of a society should be. Among them would be
the kinds of things you're talking about.
We would have to establish what are our moral obligations to the
next generation, to children, what are the moral obligations of
our stewardship of the next generation, the kind of moral question
that would be duty to the specific question, the economics and the
politics that go with it. That should be given consideration as
DR. MCHUGH: Just to press on on the topic Gil was
bringing up, I think that one of the issues about our obligation to
children comes from our recognition of their vulnerability within us
but also perhaps some recognition that they seem to thrive best under
certain circumstances. We are going to talk about that tomorrow and
the other circumstances.
The government has to come in, particularly in relationship
to the breaking up of those circumstances. Those circumstances
aren't simply financial, although financial can play a role in it.
One the major protectors, as we know, of children and the
place where they seem to thrive the best is in a family. And I've
been involved in lots of discussions as to whether the American family
is a dead thing now or whether there are so many kinds of families that
you can't even talk about what is a better family than another.
I hope I am going to hear from the people who are going to
talk with us about why it is that the family seems to be the best arena
to bring the children up. Even a family that has troubles and is poor
brings kids up a lot better than state systems seem to do and why that
is and in what way we can encourage policies and processes in actions
to make sure that the family continues a healthy thing. So that is one
side of it.
The other side of it is, again, just a stirring side. And
it relates a little bit to what Gil is saying and what you're
saying, too, Dr. Pellegrino. And that is that those of us who are
parents and who have been parents often discover that we have done
things, some good things and maybe some bad things, that amazed us that
we did that. We didn't even know we were doing it.
And something happens later in life. And the kid says,
"You know, that was this." And that can't happen unless
there is a family structure.
I've told Leon this story. Stories are really good
about things like this. And I'll tell you this story. It's
about a son of mine, who is a most successful banker now and in this
business of derivatives. About two or three years ago, I was taking
care of some patients on the psychiatric ward tied up with cocaine who
came out of the derivatives business. And I said to them, "Hey,
CHAIRMAN PELLEGRINO: It's better than going into it.
DR. MCHUGH: — I said, "how did you get into
this? I mean, how did you get into the cocaine?"
And they said, "Well, you don't understand. We derivatives
guys, we are rich as Croesus." My son doesn't share those
things with me. That's good. And he said, "But we've
got so much money we're vulnerable to taking up this stuff."
So a week later I am talking to my son on the phone. And I
say to him, "Hey, listen, I hear this is a vulnerability of you
people. You've got so much money you're blowing it and killing
your brains. I know you're okay. I talk with you. You don't
seem to be using it. What's the story here?"
"Well," he said, "there's something behind that."
He said, "I'll tell you." And here is the story.
He said, "Do you remember back when I was a freshman in high
school? We got a new machine in the house, one of these tape machines.
And one day you were there and I was there after school. And you
just got this new tape of a reading of F. Scott Fitzgerald's
"Yeah, I remember that."
"And we put it on. And, Dad, you are like F. Scott
Fitzgerald. You said I should listen to this."
I said, "I remember that."
He said, "Well, you know what the story is? The story is
this man who had really broken up with his wife, who was trying
to regain his child, who was being raised by fundamentally his in-laws
"And he comes back. And this is in the early 1930s.
He comes back to the Ritz bar, where he is going out to get the girl.
Through a series of unfortunate acts, he meets the girl, has some fun.
"Things seem to be going okay. But then it blows up, and
he loses the chance to bring the child. He goes back to the Ritz
bar. And the guy in the Ritz bar he sees says, 'Well, hi, Mr.
Wales. It's nice to you see. I haven't seen you for a
long time. Like everybody else, I guess you lost it in the bust.'
And the guy turns to him, and he says, 'Well, no. I lost everything
that was important in the boom,'" to which my son said,
"And, Dad, I'm not going to lose it in the boom."
Now, you know, whoa. This was such a telling experience.
I didn't have him listening to F. Scott Fitzgerald to get this
message. We were just filling in a little afternoon there in
Baltimore. So keeping him off the streets is something. But, you
know, that only happens in families. And it's scary. Suppose I
put something else on. What other message could I have given?
CHAIRMAN PELLEGRINO: It might have gone the other way.
DR. MCHUGH: What's at stake? So all I'm saying
is reiterating I think what was said before. We need to know and talk
about and hear from people who know something about children about what
and why certain kinds of relationships seem to be the best for children
and how those seem to happen for their flourishing and bringing them to
the next step.
We also need to appreciate that we parents are on spec all the
time. The very times when you don't think you're doing
anything — I mean, I have given my sons and daughters regulations
and rules and "do it this way." Nothing. Don't lose
it in the boom. That's what happened.
CHAIRMAN PELLEGRINO: Thank you.
I have Dr. Carson and Dr. Lawler.
DR. CARSON: Okay. I think there are probably
few more important questions that we could possibly tackle than
children raising children, how vulnerable they are, and what our
responsibilities are toward them.
You know, as a pediatric neurosurgeon, I have an
opportunity to get involved with children frequently the first day of
life and follow them for many years, right up through adulthood.
It's fairly easy to determine what kind of people they
are going to be based on their environment, based on the people who are
raising them. Very seldom are we wrong about that, which seems to
indicate that there probably are some basic tenets to raising children
and to the environment in which they should be raised.
That's on a family level. On the societal level, we
have to recognize that in a city like the one we're in right now,
we're looking at a 50 to 60 percent dropout rate in high schools.
What happens to these young people? You know, they end up in prisons,
in the penal system, where we have to pay for them. We have to be
afraid of them when we walk down the street. We have to protect our
families from them.
And, as a society, we have to recognize at some point that for
every one of them, that we can keep from going down that path of
self-destruction. That is costing us less money. And maybe that's
the next person who is going to discover the cure for cancer or
new energy source.
And we really just can't afford not to do it. And we
need to make it I think into a high moral priority, but also it's a
logical fiscal priority.
DR. LAWLER: Well, I am reluctant to speak after these
eloquent physicians, but, nonetheless, let me introduce an elementary
political science point.
This morning Robby was talking about the great Declaration of Independence
and speaking of the equal dignity of all human beings, but it doesn't
really. It speaks of the equal liberty of all human beings.
And if you think about it, the great offense against equality
and liberty in America, in a way the great injustice, is the persistence
of the family. A long as we have families, as Walzer points out,
there will be great injustice because the most important determinant,
as Paul pointed out, to how you turn out in life is the quality
of your parents.
And you have no responsibility for that. There's no
justice there. We shouldn't do away with the family because
communism doesn't work at all, but we should distribute parents by
lot. Otherwise it's pretty unfair.
So when I say that in class that the main reason you nice
kids with good manners who can sit there silent while I babble on for
an hour are sitting here is because you have good parents. In 88.7
percent of the cases, that would be it. You're not so responsible
for it yourself. You have good parents. All right.
And so the family is very unequal. Parents are an unequalling
capability and in a more troubling way, unequal in love for their
children. And there is no greater barrier to liberty, as Walzer
points out, than children. He says — this is in a remarkably
conservative article — "Children are obviously a threat
to the absolute freedom of the affair." So there are affairs.
And then there are sexual relationships that might produce children.
So the great demand of our time is for safe sex; that is, sex disconnected
from the risky business of birth and death.
So it would seem that the progress of America down the fond
roads of equality in liberty inevitably poses, in effect, a challenge
to the family. So in terms of our optimistic or happy presentation
this morning, we can say in many ways, things are better, but it would
be hard to say, I think, that families are better in America than ever
before. And we have to take seriously the question that the great
principles of equality and liberty may only be ambiguously good for
families or have good and bad effects on families.
Yet, as Ben just said so well and Walzer says, too, the family
is a kind of welfare state. If the family is a kind of a welfare
state, to speak in a corny way, you pay in love. Right? And if
the family as a welfare state stops existing, then the welfare state
as a welfare state will have to come in. And it will cost us a
And so as we talk about in our report on aging and care-giving,
because the family in some respects is weaker than it has been,
we're going to have a lot of lonely, old, dependent people who
can't rely on their families. And no one has any substitute
for the government stepping in in a big way the government has not
stepped in before.
So I'm not talking about these. I'm not giving —
I am giving a lecture, but I'm trying not to give a polemical
lecture here except to lay these things out as political problems,
which I think exist prior to the problems Janet brings up and Robby
defended our administration against.
CHAIRMAN PELLEGRINO: Gil?
PROF. MEILAENDER: I want to come back to Paul's and
Ben's comments. I mean, yours is a different angle, Peter. And I
won't try to comment on that at the moment.
This is an uncharitable thing to do after Paul says he is
sort of agreeing with me and now I am going to add a sort of caveat to
what he said.
PROF. MEILAENDER: At one level, it seems right to say, as
Paul did, that we need to know more about what sorts of structures
really conduce to rearing children well. And Ben said, you know, you
look at the different structures and you can predict and see how things
are going to work out because you know that certain things are what
children need and so forth.
I certainly don't wish to deny that. That's true. I
think what I want to say is that it's only safe to make those
claims if you say another thing as well than the thing that I thought
came out of the readings because, you see, you also Paul, in addition
to saying that we need to know kind of what the best ways to raise
children are and so forth, you also said in telling your story "We
don't know what we're doing." Okay?
And I think it's only safe to make these other claims
about the best way to raise children if you simultaneously always
remind yourself that we don't know what we're doing, by which I
mean there is a great mystery here, the mystery of the human person, on
which we're laying hands as we try to rear children.
And so there is a sense in which you see you are always
giving the child up to the wilderness in terms of giving it. The
question is whether you know it or not because you may do everything
right and life turns around in terrible ways on you. And you may not
do things very right at all. And somehow the mystery of the person in
that child turns out well.
So, of course, that's not an argument for saying "No
matter. Pay no attention," you know, "Just let children
raise themselves." But it is an argument for saying there
is something dangerous about thinking about that unless we constantly
remind ourselves that there is a mystery here that we're not
just shaping and forming. And our forming is only safe when we
CHAIRMAN PELLEGRINO: Bill?
PROF. HURLBUT: Well, listening to these two comments,
there is one little thing to add. It seems as though we don't know
what we're doing more broadly than just with our children and that
our children help align us with our deep lives.
I know it's an ancillary point, but it does strike me that
part of justice to children and dignity, the dignity of children,
is to be found — how do I say this properly? — in the
dignity of the adult being properly aligned with life.
I thought the Tolstoy reading was really wonderful. And a
couple of points in it struck me as very strong. Running through the
whole thing was how this event was transforming the man whose child was
born. And you could just feel that it was drawing him back down into a
life that is — I don't know what the right word is — authentic,
real, more full, true to his dignity.
And it was broader than the child itself. One of the lines
I really liked was where it says "That feminine world, which since
his marriage had received a new and unsuspected significant form, now
rose so high in his estimation that his imagination could not grasp
In other words, this process of bringing the child into the world had
taught him what the affair won't teach you and drawn him into
a coherent whole where he speaks of tears of tenderness, unreasoned
joy. His heart was bursting with both pity and fear, a sense of
purity, a sense of hope, a piece of his soul soaring. These are
all things we all want for our lives.
I teach at a university where a lot of the students have
great potential and, therefore, have been stirred to a lot of high
goals in terms of career. And I keep wanting to say and do say to my
students that, whereas, not everybody will have children, most people
do and don't forget to at least consider doing it, having children,
because it's the central unifying theme of human existence for the
vast majority of humanity.
And it's amazing how next to children cocaine seems so
trivial and so undesirable in my experience. I have no experience with
CHAIRMAN PELLEGRINO: I was going to say you shouldn't
PROF. HURLBUT: But I do have experience with
children. And I think what it does is it lures you away from so
many of those selfishnesses and degrading qualities that prosperity
seduces you into.
Well, maybe I've said enough about it. My main point
is that it seems to me the dignity of children is inextricably wrapped
up in the dignity of the adults.
DR. GAZZANIGA: This is directed to
Leon. The bureaucrats talk about something called mission drift.
I'm wondering if we're drifting here in that I remember
in the first days of the Council, when you were soliciting ideas
for discussion, one of the caveats you always threw back was that
this Commission, this Council was supposed to put its teeth into
ethical issues that were borne of biotechnological advancements.
And now we're into a quasi-political discussion of the ethics
of this or that social program, which is an area of discourse.
But is it the one that we have been assigned to examine?
If anybody can draw a thread between the original executive
order for why we are here and what we are currently talking about,
it's got to be you.
DR. KASS: Mr. Chairman, may I? I
don't know where this particular topic is going. It's an
exploratory beginning. The first charge to this Council under its
duties of advising the President was, you're quite right, to
not pronounce this or that right or wrong but to explore the human
significance, the human and moral significance, of advancements
in biomedical science and technology.
Point three, in everything that we have done to this point,
we have tried not to simply be driven by the technology as if the
technology were somehow first in human life, but we have tried to begin
with those things in human life that we're trying to promote or
those things that we're trying to defend against threat.
We have not yet I think identified what the precise
concrete issues affecting children are that would justify our efforts,
but if you are going to go into the field of bioethics and worry about
the effects and here I mean not just of new technologies but also of
the new way of thinking about childhood, whether borne of the advances
of neuroscience so that as we talked previously, when we had all of
these people in on the development of the nervous system and what would
be required, in fact, to take advantage of this new knowledge, so that
particularly the first few years of life were opportunities for real
neurological growth and development of the brain in healthy ways, I
think it behooves us to spend a little time. I don't know
what's on Ed's mind on this, and he should correct me if I am
But you want to begin by thinking about what actually is it
about children that matters to us? How do we conceive of them? How do
we somehow think about the ideal and what the obligations are? How do
we recognize those places where we're very far from the ideal and
see how technology can or cannot help?
Now, if I may, it remains to be seen, but we have got a whole
series of technological innovations now working their way into children.
New scientific discoveries are affecting what we think of the proper
intellectual and emotional rearing of children. It might be that
subsequent sessions touch more closely on that.
I take it that the purpose of this discussion is somehow to
think more generally about what the devil are these little creatures
and who is responsible for them for what in some kind of inchoate way.
Now let me just add one thing. I'm struck by the
degree to which biomedical science and not just biomedical science but
also social science begins to intervene into giving an account of how
things go wrong or how things can be made right, that we in some ways
lose sight of the perspective of, let's say, the household and real
life so that you have an account, for example, in the paper we are
going to be discussing of a road map for certain kinds of stages in
which there is not a peep about such things as impulse control or
toilet training or the development of habits of things of that sort,
which if you start from the household of the parents, who don't
somehow begin with the medical parameters, of which sorts of things are
being met, become sort of uppermost. And one begins to wonder, I
think, at the outset, can a rich bioethics address some of those other
It's very important if you want to diagnose autism to sort of be
able to look for its markers. It's quite a different thing
if you want to describe what healthy child-rearing would be and
what people owe their own children and what the community owes those
children that have had an unfair disadvantage.
So at least I am always more willing, Mike, to stumble
around in conversations more if the end result is not known from the
start than you are. But I would like to think that this is somehow a
preliminary conversation to have in our minds. What do we really think
about when we see a child? What are its needs? Who is responsible?
Is it right that if Gil says to us, you know, for all of
your great efforts to try to manage all of this, you should remember
that you are at the mercy of unknown things and you can't control
it? Do we then want to say to Gil once he said that, "Yeah,
that's true, Gil, but I'm going to act as if the ten percent
that is in my responsibility I'm not going to fall down on."
It's these sorts of attitudinal things that it seems to
me affect very much the larger question once you get into the
particulars. So that's one man's view. I don't know if
it's the view of the Chairman or of the people who put together the
readings, but —
DR. GAZZANIGA: There is a famous story of a famous
developmental psychologist at Stanford who had his first child and he
came to class. And he says, "There's a theory of child
development." And he would tell the theory about his first child.
Then he had his second child. He came to class. He says,
"There are two theories of child development."
DR. GAZZANIGA: As someone with six children, I guess I
have got a ways to go. With six children, I would have at least six
theories of child development. And these discussions go on, as almost
my last case in medicine story, right?
And while all of that is going on, there are people who
study these things. And there are people who examine what are the big
factors influencing child development. And it all comes out to it
looks like it's the unshared environment that has the biggest
effect on child and unshared environments, that it's not the family
environment, it's not the peer environment, it's the unexpected
and unshared. And there's a whole analysis that goes into this
sort of thing.
That is an area that I don't — I mean, I understand
your point that we want to see what the endpoint is. And then once
we're kind of clear on that, we'll see whether any of these
biotechnological advancements that are around the edges are impacting
that in any way.
I understand that's the strategy, but I don't have
a sense that we're getting there because it's such a —
I'll shut up — I find it sort of personally violating to offer my
opinions on child development because whatever I did, it worked. And I
got more with Paul's that it's probably the afternoon that
you've forgotten about that had the biggest effect.
Anyway, I think we should be clear about when we're
starting something, why this relates to the initial charge of the
Committee so that we have a sense of structure.
CHAIRMAN PELLEGRINO: Dr. Carson?
DR. CARSON: I will go out on a limb here and try to
create a relationship between advancing technology and child
development. I have noticed that one diagnosis has proliferated
greatly over the last two years, and that's attention deficit
disorder. Now, either people didn't recognize it when I was
growing up or it has greatly increased.
One could entertain the question of whether or not there is
a technological reason for this. Now, think about the fact that
nowadays, as soon as a kid is old enough to sit up by himself, a lot of
people stick them in front of the television. Zip, zip, zip, zoom,
zoom, zoom, that's all they're seeing all the time. I think
that probably has an effect on that developing brain.
Now they're a little older, three, four, five years old. They develop
a little bit of eye-hand coordination. We hand them the controls,
the computers and the video games. Zip, zip, zip, zoom, zoom, zoom.
Now they're five or six, and they go to kindergarten.
There's a teacher in front of the classroom not turning into
something every few seconds. It's very difficult for them to pay
attention in that situation because that's not the mindset that
they have as they were growing up.
I wonder if maybe that has an impact. I have many parents
who have come in to me and they're asking me, you know, should
their kids be on this drug or that drug because of this diagnosis. And
I say, "Well, do they have any difficulty whatsoever playing video
"Oh, no, no, no. They can play that for hours and
I say, "Okay." I say, "Well, then they
don't really have attention deficit disorder" or at least not
in the classic sense. They do have attention deficit disorder, but the
diagnosis is misapplied because attention deficit is on behalf of the
parents who are not paying attention to the children. And, in fact, I
wonder if maybe technology has had a deleterious effect in that sense.
CHAIRMAN PELLEGRINO: Thank you.
DR. FOSTER: Well, I just want to make a general point
because I agree with Mike. I just hope that we can deal with things
that have an impact and that this may actually help. I don't think
that we can do anything about the fact that families are only 50
percent or something of that sort.
There's no point in us emphasizing again that it's
nice to have a family. There's a thing from Stanford about why
Americans ought to always be thankful. And one of the things is six
percent of the people, six percent of all the wealth in the world is
controlled by the United States and so forth.
But one of the things that's listed there says if you
have parents who are alive and together, you are a very elite person.
I mean, it's not going to do any good for us as a council to say
something about that.
I really have a lot of concern, as I told Ed, about this
whole philosophical discussion this morning. I don't think anybody
besides us is going to be interested in the dignity thing. The
Bioethics Commission, the philosophical people, may want to read that,
but the people who are interested in serious bioethical problems to my
mind are not going to — I had to miss last time because of Dallas ice,
but when I read that transcript, I said I just can't see what this
says, not you don't have respect for persons or things like that.
So I just don't want us to get into something that's not going
to help along these lines to say that.
Now, the one thing that I think we do know that might enhance
the future of a child, which is coming up, apart from the enhancements
that we talked about a whole lot, they've got to get piano and
so forth, these transformational, as opposed to accepting love.
I mean, I think that's fine. It's to do something about
the education of kids.
In fact, we started off about this thing when Mary Ann Glendon
and others, who were (concerned about) spending so much money on
the end of life by the government and what it's going to cost
to take care of , that we're robbing the children. That was
one of the things that started this. Janet was very much into that
and Rebecca, too.
The one thing that we know pretty well is that if you can
get a good education, you at least have the tools to have the
opportunity to look into these other things. And the American schools
The National Academy of Sciences, as you know, — and I happen
to know the person whom I think was most influential with the President
about putting in the math and science teachers. In math, we're
in the bottom ten percent of the world. And, yet, we do know that
there are countries who have none of the resources that we do that
are going to pass us up. That's what the National Academy report
They started this just for the economy of the nation. And
the president of the National Academy of Sciences says that in ten
years, maybe a little longer, that India and China will be way ahead of
us in terms of economics and everything else.
Now, if they're able to do in — you know, some parts
of the country that have the ability, they get kids they do educate and
all of this. It says something very fundamental about what we ought to
be doing for children because, regardless of their parents, whether
they're loving or not, if they've got the tools where they can
read and learn things, they have the opportunity to at least project an
economic ability to have a better life for their children and so
forth. And we know these things work.
I'm going to tell you two real quick stories. One I
told Leon at lunch today. I heard a lecture. And I am only going to
tell one part of this because I wish I could tell you about what this
person is doing for the developing world. What he's going to do is
he is going to get clean water and electricity, 14 villages in
Bangladesh now that he has invented.
He's a very famous inventer. He has a program which is called
First. If you want to read about this guy, his name is Dean Kamen,
K.a.m.e.n. He's called the Pied Piper of technology. He has
invented a home dialysis machine, the first insulin infusion pump.
These Segways, these scooters that the police ride on with gyroscopes,
he invented that. He invented a whole home dialysis center and
wanted to know how to purify water so he didn't have to bring
it in. That's what he's using in Bangladesh.
But he was concerned about schools. He went to six of the biggest
companies in the Northeast unannounced because his name was known
once it was there. Originally he asked them for six engineers from
their company: IBM and so forth. And he wanted them for six months,
put them in public schools under-developed schools. Six schools
is what they started.
There were several things that happened at the end of
this. The engineers were thrilled because now they were working with
children and doing what they always wanted to do, not work in a company
just for bureaucratic things, but they wanted to use their engineering
Because the company, because DICA builds robotics, one of
the other things they built, he built a wheelchair that can climb
stairs with a gyroscope on it. So the paralyzed patient — I saw the
movies of this. You don't have to have an elevator on the stairs.
He was concerned about this because he saw some woman trying to get up
So what the deal was was that they were to build robotics out
of ordinary materials in the schools. Okay? Now, that thing has
expanded all over the country. The finals now will be held in the
Georgia Dome. I saw it from last year. Disney bopped in for a
while and built a big million-dollar tent for this to go on.
He says in these poor schools, what you were talking about,
these kids have only two role models. One is to be a rock star, and
the other is to be a professional athlete and make millions of
dollars. And that is all they have.
They now have people who are building these robotics. And
they have a varsity system and so forth and so on. It's gotten so
big now that they are having to have regional playoffs. We're
having them to get into the finals of the Georgia Dome.
Now, what is remarkable about this is that taking people
who couldn't do anything — and he brought to the Academy of
Medicine, Engineering, and Science of Texas, where he was a keynote
speaker, some of these robots that these kids have made. And for real
young kids, they built things with — what do you call those little
plastic things? — Legos, yes, Legos. In fact, they had a picture of
Einstein that some of them had done. It was just amazing.
Now, what that shows you is that, I mean, these kids are
going to have a chance. They're excited about doing it.
That's one thing that we can do. We can do something about the
schools to build them.
On a smaller level, there is a man in Dallas who is a great
philanthropist named Peter O'Donnell. He has for quite some years
now in Dallas taken a similar thing, much less advanced than First is.
As I say, you can look up Google on Dean Kamen. And about the fifth
thing you can read about him is his astonishing life.
But what he does is that he pays. He's got a lot of
money. But he pays in the Dallas school district, which is a terrible
school district — we have seven percent Caucasians in the whole
district, seventh largest school district in the country, and
overwhelmed with people just in the country from Mexico and so forth,
don't have clothes or anything else.
But he pays teachers on Saturday morning to tutor students. All
he wants to do is for Advanced College Placement in six things,
no liberal arts, in math and so forth. And he pays the kids to
go there, and he pays the teacher to do that. And if they pass
the Advanced Placement there, they both get a prize: money. The
teacher gets money beyond her salary. And the kid gets money.
He's placing these kids, they're placing these kids, in Ivy
League schools and so forth. I mean, it's so inexpensive for
what he did. Now the Dallas school district is cooperating to make
these teachers available and so forth. So that makes a huge difference.
I'll tell you one thing. We have a high school there
called South Oak Cliff. When the Dallas schools were segregated, it
was in a really poor — they make athletic champions. They have won
the state football championship. They're known for their
The most pricey high school in the area that you live in —
only 11,000 people live here — is the Highland Park High School. And
they have always had more merit scholars than anybody else in Dallas.
Two years ago, South Oak Cliff High School had a higher percentage
of people with Advanced College Placement than the Highland Park
High School, in South Oak Cliff. Okay?
My point is that I want to get beyond talking about these things
that are not serious, and if we're going to talk about children's
things, then what we ought to do is go with the National Academy
and say we have an obligation, both from the private sector and
so forth, that that is the one thing we can do to give them the
chance to have a future where they can earn a job.
So I guess what I am saying, I don't want us to come
out and say, "Look at this," and say, "Well, it's an
awful thing that we don't have families" and to come in and
say, "Well, we ought to love our children more" or things
that are not realistic. I think we ought to concentrate on things that
I told Ed I think we decide what we are going to do the
next two years. I am not interested in just sitting around here
talking about philosophical things. There are a lot of subjects that
we might look into, and this may be one of them. But it ought to be
I didn't mean to preach, but I'm just saying that this
guy Dean Kamen and Peter O'Donnell changed what I think about
what we ought to do about children. And, as the Aational Academy
says, this is not just altruistic. The whole future of the country
depends on it.
With all the crashes, what has happened to us, democracy
works when you have a middle class. And the middle class is
shrinking. I mean, all the data show that that is the case. I mean,
the stocks are owned more and more.
You know, so if we don't have a middle class, you
can't be a middle class if you don't have enough to work, you
see. I know that you all know that, but I just don't want to hear
again what we have said.
Raising kids. You know, there is an old biblical
statement. And what it says is — Kierkegaard wrote a whole chapter on
this one time — "Love covers a multitude of sins." Okay?
You have told the kid story. One time my kids, I said,
"Why do you love us when all of your other friends when they are
in high school don't seem to care about their parents?" They
said, "Well, you and Mom had lots of temporary fits of insanity,
but we always knew you loved us," you see. So love covers a
multitude of sins, you know, if you really love somebody. Okay?
It's the last thing I'm saying today. Okay?
CHAIRMAN PELLEGRINO: Thank you very much. Thank you.
PROF. MEILAENDER: You should
want to sit here and talk about philosophical things, Dan. And
the reason is — well, there are several reasons. One is anyone
interested in that chapter by Kierkegaard, which is one of the chapters
in The Works of Love, knows that that is an extraordinary
philosophical discussion of what love means and that Kierkegaard
does not for a moment think it is possible to talk about sort of
everyday life without being forced into those larger conceptual
And I think that is part of what has been good about what
this Council has done so far, that we haven't ignored particular
questions, questions that you might call questions of public policy,
but that we have always been willing to think about them in larger ways
that don't just assume that the way people frame them at the start
is the right way to frame them.
Today, I mean, we're doing two different things. The
dignity stuff this morning you say nobody is interested in it. All
sorts of people are interested in the question of who has human
Remember the Terri Schiavo argument? I mean, what do you
think? The dignity language was just coming out our ears at that
point. To clarify, to try to think about whether it is helpful and
useful, whether it actually gets us anywhere would seem to be an
important thing to do.
The children thing, I mean, I don't know where this is
going to go either, but, see, I don't assume that I know what we
want to do when we educate a child. What are we trying to accomplish?
To what degree is what we are technologically able to do
with medicines, for instance, driving our sense of how we diagnose and
treat children's problems? What degree of control is good for
parents or others to exercise over children in the educative process?
I mean, we're never going to be able to ask practical
questions unless we do think about those things, too. So it just seems
to me that while I don't wish to disagree at all that we would hope
at some point we'll say something that, you know, might make some
difference to someone's life somewhere along the way, we don't
suppose that saying that can be done without raising larger, deeper
The only question is whether you're going to be self-conscious
about what you think about those larger, deeper questions or whether
you're just going to sort of assume some things along the way.
There are going to be those deeper beliefs. And I think
part of our task has been to try to talk them through, even if it takes
us a while and we sort of stumble along and we're not quite sure
where we're getting for a while. But that's the genius of the
DR. FOSTER: Well, I don't object to you or me or
anybody else thinking about these problems and so forth. I just am not
sure that a Bioethics Council is where one ought to do it or that — I
don't know how many people bought our anthology about these
readings and so forth. I mean, maybe Leon does and so forth.
We got a lot of publicity on the stem cell things. And I
think the aging and the enhancement things, where a number of people
other than philosophers and so forth, read, I mean, I'm not against
But what I wonder is, are there other things? We talked a
little bit about this today. I'm very worried about the ethics of
science. We have had these huge frauds that are going on. They're
cheating everywhere. There's another one coming out.
I'm worried very much about the prostitution of
scientists with pharmaceutical houses and so forth. I mean, these are
real bioethical problems that one ought to consider looking at to make
Now, Leon asked me at lunch today, said, "Well, maybe the
Institute of Medicine should be the one to look at this."
But somebody needs to look at that and make some comments about
it. That to me is maybe nowhere else. And we can find out because
I can ask the president.
We always know these studies that the IOM is doing.
I'll be happy to ask Harvey Feinberg whether this is in their
purview. If it is, I would much rather them do it.
We have got the issues of commercializations that are going
on. We can't get transplants done in this country. You go to jail
if you try to pay somebody for — you know, it's a felony if you
try to pay somebody in the country. People go out today.
I think we ought to look at that and say, "Let's take
that away." We ought to pay (families of) brain-dead patients,
particularly the poor, for the donation of their organs for use.
I mean, already you have to pay UNF $21,000 for a liver. We ought
to free that up so that the you could — the insurance companies
and so forth. It takes five years to get a kidney in Dallas, five
years to do it. Your dialyzing people all the time costs a fortune
and saves the things.
What I would do is that I would say, "Look, if
you," particularly undertakers in poor areas, "don't want
bodies cut up" because it makes it harder for them to embalm them
and so forth, they tell them, "Don't let anybody donate."
So that's why we have so few donations in minority
groups and so forth. I would come in and say, "Let's look at
this. Is it illegal and immoral and unethical to pay people for their
organs if they're brain-dead?" I'm not talking about
living donors and so forth.
We might be able to make an impact on the block of one of
the most important things in the country that would save us money and
save a lot of lives to do it.
That wouldn't take a great deal of time to even figure
it out. You know, we started talking about that at one point, and we
didn't do anything. That I would say would be a great practical
It's not unethical to pay for somebody who has been
declared dead to free up five or six organs that you might use for
other people. That makes sense to me. That makes sense to me to do
It doesn't mean that I don't worry about families
and all of these other things and maybe we ought to do both, but that
is the sort of thing that I would like to get us in and be a real
Bioethical Council that would have impact not so much on the
I understand that you have to probably — I couldn't
disagree more with some of the discussions here. I just don't
think that is what we are going to be paying for. That is the point.
So I don't really mind about you thinking about it, but
I'll tell you what —
PROF. MEILAENDER: Just keep quiet, right?
DR. FOSTER: I'll bet you that this Council after
the stem cell thing would get real — we have had a lot of praise —
recognition if we took a couple of tough problems like this and
struggled with them and said, you know, "We're really
Everybody talks about the greatness of science, but
we've got a lot of problems there, as we said this morning that we
have to do.
CHAIRMAN PELLEGRINO: Thank you very much.
One more comment, two more comments? Please?
DR. SCHAUB: Yes. I just wanted to get a quick comment
in about the assigned readings. I was interested in two of the
reflections that arose out of the Tolstoy reading.
Gil, you mentioned that it's the parent who is rendered
vulnerable through the birth. And, Bill, you spoke about the dignity
of children being wrapped up in the dignity of the adults.
It strikes me that there might have been a good reason why the
original formulation, the original biblical formulation, was not
what do parents and society owe children but, rather, what do children
owe their parents? And the divine commandment says, "Honor
thy father and thy mother." And that obligation is not one
that expires on the age of majority.
I suspect that we won't do better on our obligation to
preserve, nourish, and educate our children until motherhood is again
honored by society and fatherhood is again honored by society. And I
think it is a perplexing question to think about how you do that in the
kind of liberal order that Peter referred to.
CHAIRMAN PELLEGRINO: Thank you.
PROF. GEORGE: Dan, in your most recent set of comments,
particularly toward the —
DR. FOSTER: I know there were too many.
PROF. GEORGE: All interesting, but toward the end of what
you just said, I think you raised some issues which may very well be
issues that we should be examining and maybe should be moved up near
the top, where we could actually make a contribution. I'm not
quite sure in advance what the outcome would be, for example, on the
question about purchasing organs.
I mean, I would want to hear. I mean, obviously you have
thought about this a lot. I would want to hear more argument about
it. But it does strike me as the kind of thing that really ought to be
examined. And we are in a position to examine.
You said something else that really startled me or perhaps
if I heard you correctly. I thought you said in the course of your
remarks that the cheating in science is fairly widespread.
Now, in light of these most recent scandals, I have had
some discussions with my own scientific colleagues, who assure me that
it's just a few bad apples and that science in general is in
healthy shape from an ethical point of view.
Now, if it's widespread, that seems to me to be a very,
very important thing because it would mean that the internal mechanisms
of the scientific community for preventing and dealing with corruption
are not working well.
Now, I don't know where one would go from there, but if
it is not just a few bad apples, boy, that opens an interesting
question for us, I think.
DR. FOSTER: I certainly didn't mean to imply that
it was widespread. There have been some major things that have come.
It's the pressure to achieve. You're going to get a Noble
Prize for this thing the first time I certainly didn't mean.
I think that most are, scientists are, responsible, but the editor
of the Journal of Cell Biology in regard to the Hwang paper,
you know, everything in the 2005 Hwang paper was made up. There
was not a single human line that was done.
But in commenting, the science editor said, "Well, we leaned
on the reviewers." And the editor of the Journal of Cell
Biology said that he had turned down nine papers accepted by
the reviewers for his journal because, as he looked at the papers,
he thought that the figures, like those cell lines that were in
the Hwang, were fakes. And he said editors can't escape from
the responsibility for doing this further.
There is a huge pressure on the best journals, but this is
known that every journal wants to have the hottest topic. Okay? Now,
I did at lunch, but I'm not going to mention the journal here.
Just take one of the very best journals in the whole world
scientifically. And an expert in a field reviewed who they had asked
to write a review of a relatively new scientific discovery. And she
had been asked to review a paper that was from another country.
It was a foreign paper. This was in the end of the year.
It was in December. And she turned the paper down. They published it
anyway. And the editor called her and apologized. She said,
"This is such a hot topic that we cannot have our index for a
whole year's work not have that subject listed in the index; in
other words, we can't let journal A and journal B have papers on
this new discovery and journal C, us, not have it." In other
words, the editors did an unethical thing. They turned down a paper
for monetary and prestige reasons that our journal covers.
Now, I don't know how often that takes place, but this
is written about. So that's another thing that I think you could
want to talk about with just helping to say — really, all I'm
talking about is just helping to say again, you know, what are the
standards or things that we need to do? I certainly don't mean to
think that this is widespread.
As an editor, I would say in one five-year editorship that I did of
a major journal, I only had three, at least three, things that were
cheating that we found out about. And I found out about two of
them by chance to do it. So that's how small it was in just
one journal. So I don't know.
CHAIRMAN PELLEGRINO: I see some hands flicking. And
we'll get to both of you, but the time is catching up on us. I
would like to make a comment also toward the end.
Paul? Did you have your hand up, Robby? No. Okay.
DR. MCHUGH: I just have a small
comment about the cheating business. None of us in America, especially
those of us working on this Council, believe that it was just the
pressure of science that led Science magazine to publish
There was a political agenda there. And they got burned on
it. And they should admit it. They wanted to show that America was
falling behind because of the President's decision. And in that
way, they got burned for it.
There are many, many reasons, some of which Dan has
mentioned, that lead to fraudulent behavior, not the least amongst them
the political actions in relationship to this very vexed subject in our
CHAIRMAN PELLEGRINO: Thank you.
Well, sitting here listening, I, first of all, want to
thank you. I think this part of the discussion has been very rich and
very important to those of us who are trying to work with you to know
where we go next.
I think we have heard two sets of worthwhile problems you
all agree with: one of the more general in nature, a very important
issue; and one a very specific one.
I would like to tell you that, at least in my mind, I have
been thinking seriously of not necessarily looking at those
exclusively, that we could do one and the other as well,
simultaneously, I hope a good job of both.
So I would think in the next coming meeting, we have
already talked, some of us in the staff, not the staff but with the
staff, about the organ donation question because that has been touched
in the past. And picking it up now I know is of interest. And I think
it's of great interest.
I personally in talking with Dr. Foster and my own
experiences of 25 years of investigation, the context of science has
changed. It has changed in a way that makes it very difficult for
scientists these days to put stimuli and pressures on them that are
very, very unfortunate. I think they are worth looking at. When I say
"worth looking at," to come next time with some presentations
that would open up these issues and also to continue to look at what
are the issues.
I guess my approach to the children was naive. I personally would
have asked it from the beginning in a different way perhaps. And
that is: What are our moral obligations?
We have, all of us, experiencd with children in very different ways.
And it would be a useful exercise to put down and just say these
are some of the obligations we see for the future generation of
our stewardship for those children. And put it in ethical terms
against the background of some of these larger issues. I tend to
start from what is the ethical problem? What is the problem we
have? What are the data we have and so on?
I'm just giving you some insight as to my own
thoughts. I have been very quiet in most of these meetings, and I will
continue to be mostly quiet, but I think we are at a point now where we
need to decide on our agenda.
We don't have that much time in our existence left,
really, basically. We know what happens at the end of the
administration to groups like this. And I agree thoroughly with you we
should do something that is very, very useful. You have done it.
But I think our next step will be to look at maybe these
three issues, continue to look at the children's issue, make it
more specific in terms of the moral obligations that we might see and
envision, maybe put them before you and see how you think about them,
look at the question of the context of the atmosphere of the science.
I was worried about this 25 years ago. I think we always
heard there are only a few bad apples. But if you look back at the
history of the past 25 years, there have been more than a few bad
apples. I'm not blaming anybody, but this does happen.
So when I have been asked to write about this, the ethics
of scientific research, I have talked about rules, regulation,
principles. I've talked about the character of the investigator.
Now, what do we do about that? And how do we handle that? You might
want to go out in a different direction, but I recognize that as a
Does anyone feel that this is a grossly inadequate way to take
a next step? Take these three issues: the organ transplantation,
which you've have talked about in the past. It is an urgent one.
And I like the scientific change in the context: hat are the ethical
problems of today compared to someone said the other day I was talking
to a whole attitude of scientific research has changed? It used
to have the good of somebody else as its aim. Now, it is for most
scientists still, but some still are looking at it as an investment
opportunity. We know that. So let's take a look at that.
Can I get a quick response to that? If you want to shoot
it down or we need to have some advice on what the next steps might be?
PROF. DRESSER: I was going
to mention that at one point we were talking about perhaps doing
a report on commodification of the body. It seems to me there are
some strong connections between dignity and commodification. So
it might be that a dignity report could pave the way for the application
to the —
CHAIRMAN PELLEGRINO: I think the way we seem to be going
for the moment, Dr. Dresser, is to work on that anthology and to try to
round out the problem. So I think we probably will not be discussing
the dignity question here for a while before we have something specific
to put before the Council with the papers and so on that will be
contributed. So that will be a work. It is already on its way, I
think. And other issues could come up. I just wanted to pick two or
We have to become specific. I quite agree. And, as a
physician, I tend to look at some practical things, too, from time to
PROF. MEILAENDER: Just an off-the-top-of-my-head
reaction is that it sounds like one problem too many. That is,
see, I'm not really sure we could do — if you're thinking
of doing those three things simultaneously, I just have doubts about
whether we could manage it. But that's just my reaction.
CHAIRMAN PELLEGRINO: No, no. Well, I think I have doubts,
too. And I think the way to do it perhaps is what the architects call
fast tracking, run two or three of them simultaneously and see which
one is doing well and which one has to be dropped out.
And that will give us a little practical feedback, which we
ought to do and whether we can do the three. I agree. I feel whatever
we do, we ought to do well because you have established yourselves as
having done a very good job on everything you have done. And we
don't want to lose that by any means.
Yes? I'm sorry. Yes?
DR. KASS: Ed, just one comment on the substantive
proposals. And I had mentioned this to Dan at lunch. I think the
question of scientific integrity, the behavior of the journals and
things of that sort, is a problem for scientific housecleaning and
I can't imagine that it would look very good for the
President's Council on Bioethics to be pontificating about the
misconduct of some scientists. And if the National Academy of Science
and the Institutes of Medicine were inclined to think this problem
through, that would have a great deal of standing in the community and
a great deal of weight. I mean, it would be worth maybe having a
conversation about it.
It is my sense that it would be a misuse and would not be well-received
I think coming from this presidential body. A lot of empirical
research would have to be done to see how widespread this is.
Now, the question of commerce in these —
DR. FOSTER: Let me just say I actually would prefer
that much myself, too, if we could do it. And if the Chairman would
like for me to, I would be happy to explore this with —
CHAIRMAN PELLEGRINO: Would you do so?
DR. FOSTER: — the presidents and see if
they have any interest along those lines.
CHAIRMAN PELLEGRINO: Can you do that? I appreciate that.
Let us know. I think that's a good point. But if they're not
doing it, again, we ought to keep that in our sights.
I've just been alerted to the fact that we need to get
Dr. Greenspan on by 3:45. And if I let you loose now, I hope you will
get back by 3:45. Can you do that? Forgive me for taking some of your
(Whereupon, the foregoing matter went off the record at 3:39
p.m. and went back on the record at 3:49 p.m.)
SESSION 4: THE FUNDAMENTAL NEEDS OF CHILDREN
CHAIRMAN PELLEGRINO: Thank you very much. Thank
you very much for coming back so promptly. I know we have deprived
you of your afternoon sustenance, and I hope your blood sugar isn't
so low that your cortical cells aren't working. They do take
a lot of energy, don't they? So I've been told. Our next
speaker is Dr. Stanley Greenspan. And I've informed him that
we have not been reading curricula vitae in any detail. So he will
begin launching into the subject himself.
He is clinical professor of psychiatry and behavioral
science and pediatrics at George Washington, right here in town. And
he is going to address us on some of the issues that we have been
DR. GREENSPAN: Yes. It is a real pleasure and an honor to
be able to be here with you today and part of this wonderful
deliberation and thoughtful exploration. I'm particularly pleased
that children and mental health of children are on your agenda.
Just as a way of introducing my comments — then I have a
brief video illustration to show you of a few of the points that
we'll be making in the second part — I think many of the ethical
issues need to be framed within a larger psychosocial or
bio-psychosocial context. And when we don't do that, we tend to
get our backs up against the wall.
I think it's the same thing we're learning in terms of
international relations. Unless we see the big picture, unless we
see all the dynamic relationships between all of the factors, we
sometimes embark on a policy initiative that needs to be revised
in midstream. And the same thing comes I think with ethical issues
as well. One concrete example, an issue that gets many headlines,
is a medication for very young children, three and four-year-olds
being put on Depakote or Risperdal or Ritalin or some of the SSRIs,
like Prozac or Celexa.
Often the situation in context for something like that is a
child who seems to be out of control and a parent who presents to the
emergency room or to the physician with a desperate situation. And
obviously there is a need to deal with the crisis at the moment.
What used to happen, way back in the 1970s, is there would
be a broader approach, then. Even though you might deal with the
crisis of the moment, you would have a broader approach to find out
what is going on in the family, what is going on in that child's
life to precipitate this sort of a crisis.
Now that is not happening as much. And so the crisis
becomes a perpetual crisis. Often one medication doesn't work. A
second one gets added. And then we have three and four-year-olds on
polypharmacy. And then it comes to the attention of the media and the
press and the public and then becomes of concern to the President's
Council, as it should, on Bioethics.
Then the solution gets focused on, well, should we use
adult medications on very young children, rather than what is the
broader psychosocial or bio-psychosocial dynamic framework that we need
to be looking at, what has been eroded in our society in terms of the
way in which families are taking responsibility for and we collectively
as a society are giving support to families so that they can handle the
vicissitudes of both healthy development and challenging development.
What sort of services do we have available that focuses on this broader
And when we look at that, we begin seeing a worrisome
picture. We see a picture of a service system where it's
fragmented, where we're not providing that broad — we use the term
"bio-psychosocial," but we don't practice
bio-psychosocial. And we have families that are being encouraged
towards more narrow and simplistic ways of thinking about their
kids' quick fixes. And then we look for quick fix policy
solutions, you know, rather than long-term solutions that will produce
an adolescent and a young adult who will be a contributing member to
This is not just simply happening in poor populations or socially
at-risk populations. It is happening in the well-to-do. Also,
I can tell you as a child psychiatrist who in my research and in
my practice, I see every socioeconomic group. It's happening
across the board.
I see as many what I call multi-problem, multi-risk families from
the very wealthy and among the very powerful in Washington as I
do among the very poor. And, unfortunately, it's the same qualities
in the families, even though some families have the means to do
much better. So that's the broader point I would like to emphasize
for our discussion.
Within that context, you know, I just want to focus in on a
few things that reflect some of our current knowledge that can be put
to very good use. And, again, I'm not sure if this is completely
the purview of this Council, but I think it should be. So if it's
not, I'm hoping it can be embraced because as many voices that I
think converge on these themes, the better.
Some of the issues, again, that grab the headlines, are we
labeling children with mental health disorders, such as ADHD, which I
know you were talking about just a few minutes ago, when they are
simply showing normal variations?
Are we helping or hurting when young and younger children
are put on psychiatric medications, the issue you just addressed,
depression, anxiety, bad behavior? You know, we're doing it for
many things now.
Is increasing testing of school children encouraging rote memory
skills, teaching to the test, and decreasing critical thinking skills
or fueling better education? Big issue. I think it's ethical
as well as educational. Is full-time day care for infants and toddlers
and preschools helpful or harmful? Very big issue.
Back in the 1970s, only a small percentage of children were in
out-of-home care. Now, over half the nation's children are
being reared in the first four years of life out of the home, very
important issue because it's no longer just an option. It's
now in many circles a favored and recommended alternative to family
In what way can early identification, intervention in
mental health and developmental problems be harmful? Again, these
questions grab the headlines, but the answers identify the components
of a children's mental health and education policy.
A children's mental health and education policy must
begin with a definition of what we think of as healthy development. It
has to be a positive framework, promoting healthy development, and then
seeing problems off of that.
Again, here we have become too symptom-based when we think about
children. So we identify the signs of autism or the signs of learning
disabilities or the signs of ADHD, but we don't identify the
context of a framework to adapt to a healthy development. And we
often miss the boat. And that's where we make misdiagnoses
and we have failed policies or failed interventions.
Recently we have formulated a road map for children's emotional
and intellectual growth that can enable parents, educators, and
policy-makers to create proper goals.
The elements of the road map are neither elusive nor
complex and, in fact, are familiar to most parents. And here, this is
a road map that I have personally been involved with the research on,
starting back in my days at running a center at the National Institutes
of Mental Health and continuing to the present day. And it's a
road map that we have a lot of data and evidence for.
We recently tested it on 1,500 families... down to a simple questionnaire
that can ask parents questions about this road map. And it distinguished
normal from problematic children. It distinguished different groups
of disorders and also validated the foundations for healthy development.
So this is now a well-validated road map. And the interesting thing
about it is the same milestones that predict social and emotional
competency predict intellectual competency.
So we don't have to be thinking about what is going to
make a child smart and what is going to make a child mentally healthy.
It's the same processes and the same early milestones. So we can
have a quick look and give parents information and give our
pediatricians and give our day care workers information that will
promote healthy intellectual and emotional growth. And briefly they
are the first capacity is helping a baby be calm and regulated and
attentive to sights and sounds and smells, the sensations around them.
This starts in the first months of life.
Number two, forming that first relationship and then
continuing to deepen it with great intimacy, early relationships and
the ability to form that relationship is critical for all later
skills. And the babies who don't have it or children who don't
develop it later because of access to a nurturing parent have lifelong
difficulties, often winding up in delinquency and antisocial behavior
if they're fortunate. If they're less fortunate, they have
mental retardation and possibly delinquency.
Third is the ability, still in the first year of life, simply
for a baby to form purposeful two-way communication to interact
with gestures, to point, to reach, to smile, to vocalize in a responsive
way to the parent and the parent to be responsive back, to get what
we call circles of communication back and forth, back and forth,
signaling, very easy to observe, very easy to ask parents if the
baby is doing it with them. And that's the basis for learning
to be logical, learning to be causal, learning to read emotional
signals, learning to be a social creature, learning to adjust to
rules eventually. It's again a foundation for everything else.
The fourth we call shared social problem-solving, where
toddlers are already becoming scientists. They're taking mommy by
the hand, walking her to the toy area, pointing to the toy they want,
and then motioning "Pick me up."
Well, this is the beginning of pattern recognition. This
is the beginning of scientific thinking. This is the beginning of
figuring out "I've got to do step A, B, and C to get to step
Now, again, parents that facilitate this kind of
problem-solving produce kids who are already problem-solvers before
they talk. And when they use words, they know what the words mean
because they were already experienced in the world and they can already
organize it in terms of patterns. So when they label something, they
know what it means.
Children who don't experience this, either because of
environmental deprivation or biological challenges or combinations of
both, again don't have that foundation for healthy educational
growth or healthy emotional and social growth because this is necessary
for reading someone's emotional signals as well as for learning to
read and learning to do math and learning to write an essay.
The fifth milestone is the ability to use ideas, which
includes language, obviously, meaningfully and creatively, not just
rote. You all see kids being shown off by their parents, labeling cars
or chairs or using flash cards to learn to even spell as they are
learning to talk. And that kind of rote learning is the ticket to poor
intellectual, emotional, and social growth.
On the other hand, meaningful use of ideas and creative use of
ideas, as you see in imaginative play, you see when a child says,
"Mommy, I want my juice now" and she says, "Why?"
"Because I am hungry," that child is learning to use ideas
meaningfully and functionally. That's a person who will be
able to be a problem-solver, not just repeat facts in a mindless
And the sixth milestone is the ability to connect ideas
together logically and meaningfully, answer that why question,
"Why do you want to go outside?" "Because I want to
play." "Well, why are you so mad today?" "Because
Johnny stole my toy or took my toy."
That's a child who can connect ideas together, figure things out,
doesn't have to act out, doesn't have to behave impulsively,
doesn't have great mood swings. They can figure out their internal
or their feelings, but, more importantly or equally importantly,
they can also problem-solve in school, figure out why two plus two
is four, figure out why the story has a meaning and what the author's
And then we have, which I won't go into in any detail, three levels
of higher skills having to do with what we call multi-causal thinking,
gray area, incomparative thinking, where you can see the subtleties
and nuances between things, and then what we call reflective thinking,
where the person can evaluate. This doesn't come in until 9
The person can evaluate their own behavior, their own thoughts,
and their own products so they can evaluate their own essay and
say, "This was a good essay. I made my point," "This
wasn't so good. I didn't prove my point. I wasn't
happy with my performance." They can learn from mistakes.
And this is what you need to be a self-learner. You need that ninth
level, that reflective thinking, to really be a contributing member
to society because without that, you don't have a real sense
of what justice is, you don't have a real sense of abstract
concepts of what freedom truly means. And when we bring democracy
not just at home when we want further democracy, when we further
it in other countries, we have to promote these same milestones.
Unless we get growing children to this ninth level, they
can't really embrace what Jefferson had in mind when he said the
consent of the governed because that means investing in abstract
institutions and abstract concepts, which requires mastery of all of
Right now in the United States, I worry that less and less
of the population is mastering all of these critical milestones. And
at a certain point, you do reach a tipping point, where there are not
sufficient numbers to embrace what democracy really means and what
freedom really means and what equal opportunity really means in the
On the other hand, if X percent have these capacities, then
equal opportunity, freedom, justice, and all the things we stand for
really have meaning. So this does come back to the cornerstone of our
Now, as I mentioned, we have evidence. And we have a simple questionnaire
that takes parents about 15 minutes to fill out that can give the
parents a quick picture of where their child is on these milestones.
It's now we just did the research with Psych Corp., our hard-core
assessment, because they had the resources to test it out on 1,500
families and produce it as an instrument that's available to
the general public. It is just fresh. Literally within the last
few months did it come out. That gives us tools to work with.
We also use these same questions in a survey with the
National Center for Health Statistics of the Department of Health and
Human Services on 15,000 families. And it identified 30 percent of
children who otherwise wouldn't have been identified on the
traditional health survey.
The traditional health survey asked, "Does your child
have a problem? Does your child have a developmental disorder,
emotional problem," et cetera? The answer was no.
Then they were asked specific questions from the these
questionnaires, like "Does your child relate warmly to you? Does
he respond to gestures with gestures back?" And that picked up 30
percent additional children who required services, who weren't
getting the services. And a lot of these were obviously from
underprivileged or poor households. But it showed that we can do
better in terms of early identification and preventive intervention.
Now, when we use a road map of healthy development, it
provides the tools for us to do a few other things. We can give
parents this information and knowledge. And I recommend a major
initiative where we provide this good information to parents because we
formulated an initiative called the Family First Initiative, where
families are empowered with knowledge to be the first ones on the line.
When we talk about education, we have to realize that education
begins in those first three to four years of life, when their brain
is growing to two-thirds, three-quarters of its adult size. And
the parents are usually the key people educating children.
Again, the emotional and social growth and intellectual
growth are one and the same at that early age, when the brain is
growing so rapidly. Now we have overwhelming evidence that the actual
laying down of pathways in the brain, the structure of the brain is
influenced by the environment.
It's not that the genes determine the writing of the
brain and the environment provides slight modification. Our genetic
makeup provides us with a very fundamental only beginning blueprint.
And then Mother Nature was very wise in allowing the brain to grow
depending on the environment so it could adapt to different
environments. But that makes the laying down of pathways dependent on
And so we have lots of evidence from imaging studies as
well as animal studies that the not only learning but actual brain
structure is determined by what kind of experiences we provide for our
children. So we have to provide what we are calling a Family First
Initiative, which is in the briefing notes that I sent around, where we
really empower families to know enough that they can take charge.
And it has two components: one, identifying healthy development
so they can share and enjoy it with their children; two, the kinds
of interactions that promote healthy development, not simplistic
things, like having kids watch TV or high tech stuff but the kinds
of playful interactions, like peek-a-boo games and back and forth
signaling games and things that promote engagement and relating,
you know, that have stood the test of time but that parents are
being dissuaded from doing because of misinformation from a variety
So we have to get parents back to the basics of things that
produce healthy children and give them the kinds of activities that
really work for their babies and young children.
And, number three, we have to provide parents with the warning signs
of when things are not going right, you know. And that has to be
done in a healthy framework so that it's not simply looking
for "Is my child blinking too much or is my child a little
too active?" but "Is my child failing to learn to be a
shared social problem-solver? Is he 15-16 months old and he can't
show me what he wants, can't gesture it, you know, just gets
frustrated and cries or just gets impulsive and starts hitting?"
So it's really the absence of the healthy milestone,
not so much the presence of the problem that we want parents to focus
on, because then we can help the parents to promote that healthy
milestone, which is often the ticket to overcoming the problem
And we have to do a very active campaign with our early child
care educators, day care, and nursery school educators, and pediatricians,
who help parents, who are the front line, as well as our other health
and mental health professionals, who don't get much training
or background in the early years of life, who are mostly experienced
— (en my colleagues in child psychiatry are mostly experienced
with the kids over age five). Rarely do they get a lot of work
with the younger kids.
So I recommend a Family First Initiative for parents. Also, a
second initiative I'm recommending based on this is a prevention
initiative. We could probably reduce health care costs by 50 percent
and improve our outcomes for future citizens having healthier thinkers
and healthier copers with reducing divorce rates and reducing criminal
behavior and reducing depression if we took a real prevention initiative
beginning early in life.
We have the know-how now. We really know what to do, but there's
not a sufficient emphasis on prevention in our health policy and
our education policy. And we really need to change that around
with what we now know. We know how to build healthy foundations.
And, again, it's not the quick fix. Take reading, for
example, which is high on the current agenda. Child A isn't
reading simply because he hasn't had the practice. He'll
respond well to current programs with more emphasis on reading.
Child B isn't reading because he can't distinguish
sounds very well. So when he hears the "bah" and the
"gah" and the "dah," you know, he doesn't
separate those. So he can't match the sound, then, to the visual
image. And he has a deeper problem.
We can identify that deeper problem by eight months of life
because that child in the back and forth signaling won't be
vocalizing as much because he's not decoding the sounds.
We can play games with that child where we expose the child
to different sounds while the brain is growing. By the time he gets to
school, he can decode lots of sounds. And he can then become easy to
work with reading.
That won't be with a quick fix approach. That will be
with understanding the sequence leading to good reading skills in a
broader developmental framework. So we know that now. We have
agreement among experts on that line of development. But we need a
prevention policy to really do it.
And a third part of our initiative is there are a number of
families that are very, very dysfunctional, where one generation
produces another generation of people with multiple mental health
problems and poor coping skills.
This is the 6 percent of the population that uses about 75
percent of the public services. They're in emergency rooms.
They're in crisis centers. They're using social services.
There's abuse. There's neglect. There's a heavy drug use
and alcohol use. There's heavy psychiatric illness in the adults.
We did an experiment in Prince George's County, Maryland with
these families we call them. We published a monograph called "Infants
in Multi-Risk Families." I did this when I was at National
Institutes of Mental Health. And we demonstrated we could possibly
work successfully with these very at-risk families and turn around
this multigenerational cycle, but this requires a heavy, heavy outlay
of outreach services reaching out because you're not working
with people who come in and ask for help. So you have to have outreach
for a very small percentage of families that really require it to
interrupt this multigenerational cycle of poor coping.
Now, what I want do in just finishing up is show you this prevention
approach that we have been doing. We have been applying it to children
with autistic spectrum disorders. And we have been working with
kids at early ages. And we have been helping them build healthy
foundations, mastering these milestones that I just reviewed for
you of attention and engagement and emotional and two-way signaling
and learning to think creatively.
I'm going to show you one little boy, who is about three and
a half to four, who is at the early stages of work. You will see
him in just the first consultation session, and what happens, just
as we get the parents working with these foundation pieces. Then
you'll see a boy who is the teenager, who is talking politics,
some of which you may agree with, some of which you may disagree
with, but who was diagnosed with autism as a young child and was
the product of a program that focused on healthy foundations, not
on just changing behavior. In other words, there are two philosophies
in treating autism now, one that I represent, building healthy foundation;
the other, just changing surface behaviors.
So I want to show you these briefly as just a little
example of what we are talking about them concretizing. If you would
show the first videotape?
(Whereupon, a videotape was played.)
DR. GREENSPAN: He had been diagnosed with autism. And we
were seeing him for a consultation. He is kind of in his own world a
little bit and doesn't respond to the parents' overtures.
So here you can see how he is not again relating to the
mom, to his own mommy, or interacting with her or exchanging gestures
or exchanging words but just focusing on the concrete objects.
Now he begins drifting off again. Now we start working
with him. He's in control. We're constantly enticing, luring
him in so that he becomes more comfortable with controlling the warmth
and the intimacy.
This is all about engaging. It's all about intimacy.
It's all about him feeling comfortable with intimacy. And he has
to feel in charge of that. So we entice. We move. He wants to move
away. He moves away.
We entice him back. But we let him be in charge of the
body. If he wants to kick the dolly away, "Oh, bad dolly.
You're kicking the dolly away." Okay? If he wants to feed
daddy, "That's great." Okay? We're enticing.
We will sometimes take his little thing in his mouth and
put it in our mouth to entice him because then he will come to us.
That's it, making sounds to each other. Keep that up. That's
wonderful. That's beautiful.
That's all for this tape. Here you can see how
we're building those early milestones that I was talking about.
We're building healthy foundations in this little guy, rather than
just trying to change his behaviors.
Now you're going to see just for about 30 seconds a
teenager who started off with a diagnosis of autism. And I will let
you judge for yourself how he is doing now as a teenager. Again, his
political views are his own.
(Whereupon, a videotape was played.)
DR. GREENSPAN: We can stop now. We can stop the tape
now. What I wanted you to see was his kind of logical analysis,
whether you agree with his ideas or not.
So here you see a young man. He's in one of the more
demanding private high schools of Washington, had a lot of friends,
played sports, gets good grades, going to be going to college very
shortly, probably one of the better schools.
And he's like a bunch of kids. We have a subgroup of
kids, those that we work with, that's a fairly sizeable subgroup
that are just like him now that we have followed for 10 to 15 years who
are no longer receiving any services, who are fully on their own and no
longer need any mental health care.
This surprised us. We didn't think that even a
subgroup of children — this is not true for all children with autistic
spectrum disorders. There are other children that make slower progress
and other children that it is very difficult to make progress with.
But in this subgroup, which is a sizeable number, they
surprised us in how well they did when we took this healthy
Now, just to kind of conclude my comments and then open it
up for your questions, if we use our road map for healthy mental health
and intellectual functioning coupled with a family-oriented and
prevention and comprehensive outreach and treatment initiative, we can
answer the questions raised earlier.
A picture of healthy development will enable the true
identification of real problems. They're not just symptoms.
They're the failure to meet these healthy milestones.
Medication that is being used more and more widely for
younger and younger children reflects in this context the erosion of
comprehensive child and family-oriented approaches in mental health
care. That's what is pushing the system in that direction and with
the erosion of family support.
Increased testing, if not tied to respect for variation among children
and from the importance of critical thinking skills and for innovative
teaching and for education-parent partnerships can undermine, rather
than facilitate, long-term academic development. So testing is
okay if it's tied to the broader other goals.
Full-time day care for very young children is
counterproductive if parents are able to provide high-quality care
themselves. In other words, therapeutic day care for high-risk
families seems to be helpful. However, day care for children who have
parents who can provide high-quality care seems to be counterproductive
when we look at their development.
And there is new research showing higher stress hormones in
the kids who are in day care for longer hours each day and also more
problematic and aggressive behaviors by age four and five. But we know
that four babies for one care-giver, they can't get the help they
need to master these early milestones well.
Early identification and intervention is only helpful if it
focuses on positive growth and development that would be beneficial to
all children. So a road map in these types of initiatives are
necessary if future generations will be able to cope and lead an ever
growingly more complex society.
CHAIRMAN PELLEGRINO: Thank you very much, Dr. Greenspan.
Are there questions? Dr. McHugh?
DR. MCHUGH: Dr. Greenspan, I was very pleased to listen
to you. I have worked with you before and found it very interesting.
Questions I wanted to ask you relate to two sides of your
presentation. The first one and the one I absolutely agree with is
that we are doing a very poor job in assessing our patients, children
or adults, for that matter. And we don't do what you referred to
as a bio-psychosocial study, which I would say we don't do
essentially a full workup.
And that's not because of the society, though, Dr.
Greenspan. That's because of American psychiatry, which has
decided in its wisdom to employ a checklist diagnostic system that
resembles, as I've said to this Council many times before,
fundamentally a natural field guide, rather than a diagnostic system,
or an understanding.
It's entirely different from ICD-10. DSM-IV and ultimately
DSM-V will be continuing this method, which, by using field marks,
checking off like we check off the color of the wings of a bird
or something, ultimately very quickly and with checklists leads
to a diagnosis and a penny in the slot therapeutics in which we
give a pill and a pill and a pill and see whether they — again,
I wonder whether you would agree with me.
That's my first question, if you would agree with me
that psychiatry has a lot to answer for, particularly if it's
continuing this method and discouraging the full workup of patients.
It used to be, to use the expression of William Osler, that
when you went to see a specialist or a consultant, the thing that the
consultant did was do a rectal. What has happened in psychiatry is
that when you go to see a consultant, like me or you, what you do and
what you get is a history, a full workup, a study, and a differential,
rather than a checklist. And I think it's not correct to complain
that this is society's fault, although I think the health care
delivery system now is going with us in psychiatry, letting it happen.
So that's the first question I want you to address.
The second thing is I am interested in your method of studying and
seeing patients and appreciating how they go in relationship to these
goals or elements in the developmental process. And it resembles, of
course, other developmental processes but now in a more
What I wanted to know from you because it wasn't quite
clear was whether when you found somebody who was slow in failing in
one of those developments. What you then did because it could be that
this is a very appropriate scale for picking up troubles, but does it
diagnose troubles as well?
Again, this falls back on our field right now, where we
have claimed that scales and systems like the diagnostic interview
schedule, the so-called DIS, we thought that it was carrying diagnosis.
It turned out to be very good at recognizing disorder in
the sense that a person was disordered, but it didn't recognize the
diagnosis of that disorder. It worked something more like the
sedimentation rate than it did like a diagnostic instrument. Where
does your scale fall in that relationship?
And then, thirdly, you offer us some optimism in the
treatment of autistic spectrum disorder. Is that optimism based on
controlled trials and things of that sort or is it still at the level
of your knowledge as an expert dealing with patients of this sort? So
those three questions, sir.
DR. GREENSPAN: Yes. Thank you. Those are excellent
questions. They really all converge on, I think, the same kind of
answer. I think you and I are very much on the same wavelength. In
fact, we quoted you recently in making the argument that you just made
in an article we did for a broader diagnostic system because you had
done an article for I think the AMA journal a little while back. And
we found that very, very helpful. So we're on the same wavelength.
Basically, I think American psychiatry made a turn in the
road a number of years ago when they gave up complexity for
reductionism and attempted to use the symptom approach, sort of the
term that you term aptly the field approach, to get greater reliability
and hopefully more science, but the reality is it turned out not to
yield even that. And it is misleading because it doesn't look at
the whole person, doesn't look at the complexity of human
And when you look at clinicians in practice, reliabilities
are tragically low. So it didn't even accomplish the limited goal
that it had. And now it's kind of facing that folly.
We recently brought together, just as a side note, — I think
you'll find this of interest — all the organizations concerned
with psychodynamic approaches, which tends to have a broader model
focused in on the psychosocial part of the bio-psychosocial. And
we are about to publish in about three or four weeks, but there
was an article in the New York Times about this effort, this Psychodynamic
Diagnostic Manual, the PDM.
And that's an attempt to move in this direction. I
hope you'll like that when you see it. But it's a broad-based
approach looking at personality and looking at profile of mental
functioning and looking at symptoms as well but symptoms from the point
of view of the patients, full experience of those symptoms, the
subjective level, not just the tip of the iceberg.
So I am very much in agreement with you. I think
psychiatry took a turn in the road. I think, unfortunately, the
population has been moving in reductionistic ways, too, because of
other forces in society and managed care and other things.
So I think a lot of things are converging fostering
reductionistic approaches. And I think it needs to be reversed because
it's going to be hazardous for the future.
The second question about our own identification of these milestones,
yes, that's simply — and I agree with you — the
first step of kind of identifying a road map for healthy development
that allows us to know which children need a further workup.
So it's not supposed to be a diagnostic tool. It's
not even supposed to be a screening tool. It's supposed to be kind
of a help and observation, saying, you know, what have we learned in
the last 20 years that will help us observe infants and young children
a little more effectively? And can we turn these into a series of
questions you can ask, that a parent can ask, so that they're not
just looking at it as a baby crawling?
See, historically parents were looking at it as "Is my
baby crawling? Is my baby saying first words?" And that's
not enough. We find that these landmarks "Is my baby engaging
with me? Is my baby interacting? Is my baby problem-solving?"
yields much more fruit.
And then you move to the second step, which is exactly what you're
saying, a full diagnostic work-up involving the family, involving
the history, involving the infants' biology.
And then when we develop our intervention programs for
children with autism, it's a full bio-psychosocial model of
intervention. I mean, I don't have time to go into it here, but
there are a number of — those who would like information about it,
there's a book I wrote called The Child With Special Needs. And
there's another book that will be coming out in about a month
called Engaging Autism that describes our developmentally based
bio-psychosocial approach, which we call the DIR model, where we work
with the child's development, individual biological differences and
family relationships, as well as therapeutic and educational
relationships in a very complex dynamic framework.
To answer your third question, we have been getting much
better results than before. And the answer is somewhere in between.
It's not just impressionistic and clinical experience of experts,
but it's not at the clinical trial phase.
No approach to autism actually has had good clinical trial
comparative studies yet. The Academy of Sciences issued a very good
report a few years back on educating children with autism, where they
cited our approach and other competing approaches, such as behavioral
approaches, and pointed out, as many of us have been, that we need
comparative clinical trial studies between the competing approaches
right now, because there's a whole group that is developmentally
based, which I kind of represent, and then another group that is more
behavioral and symptom-based, represented by behavioral approaches.
And we need comparative clinical trial studies, but we do have
a number of studies, small studies with control groups showing efficacious
results. We also have a study of 200 children with autism, of which
I showed you the tapes of some of the kids who participated in that
review of 200 cases. And we have percentages for the rates of improvement
that go way beyond the expected rate. So we had 58 percent that
were like that teenager you saw in our study of 200 children.
Now, this was not a representative population, but they did
start out with all degrees of severity. But it wasn't a brand new
group from the community. So I can't generalize that in the
community, we can do this with 58 percent, but I am convinced that
there is a sizeable subgroup that can have much better outcomes than
we're seeing. But I need to show that in a clinical trial study.
So we're somewhat I think in between. I'm looking
for — we have a clinical trial study planned. And hopefully we'll
undertake in the next year, year and a half. We're getting the
funding and the organizational support needed for it because, as you
can imagine, it's a very expensive undertaking and not easy to
So I am basically in general agreement with the thrust of
your comments and would second them and think we need to do a lot of
work to shift the momentum that we're seeing in psychiatry but also
in general society away from the quick fix and away from the short
reductionistic approaches towards back to understanding human
PROF. HURLBUT: I have two questions. First, when I
watched those parents, they seemed like pretty earnest parents. And if
you say that the normal development takes place in an interactive
environment, that kind of attunement and entrainment that goes on to
establish that sense of pathic communion or whatever it is,
intersubjectivity, it struck me that those parents would have been
quite diligent in that.
Actually, now, a few weeks ago, a paper came out showing
fMRI studies of kids with autism and deficiencies in certain areas
associated with Rizzolatti's mirror cells.
DR. GREENSPAN: Right.
PROF. HURLBUT: And what I am wondering is, well, maybe a
little reflection broadly on, is that just another form of
reductionism? And why didn't that child relate to his parents? Is
it that they needed to do different kinds of strategies, they had to
reach out a little further than normal? What was going wrong there?
DR. GREENSPAN: Well, basically autism is fundamentally a
biological disorder, where the children's biology is different,
making it much harder for these ordinary parental processes, even among
gifted parents — and these parents were very gifted. You saw how
quickly they shifted what they were doing with a little bit of
coaching. So it shows you how gifted they were. And the parents of
these teenagers were quite gifted. And that's why he did so well,
Autism is fundamentally a biological disorder, not a disorder
of parenting. And so the children do process information differently.
For example, children at risk for autism early in life, we see some
of them are over-reactive to things like touch and sounds. Some
are under-reactive. Some have low muscle tone. Some can't
distinguish sounds easily. Some get confused by visual input.
They can't see patterns.
The mirror imaging work is interesting because we do see
problems with early imitation, you know, where the neurons that
supposedly help with imitation, these mirror neurons, are supposed to
The problem with the research on the mirror neurons, just
as a quick side note, is that where it's an example of
reductionistic thinking, when you read the research and read the
reports of the research in the media and read it in the scientific
community, there's an assumption because these mirror neurons are
part of the physical structure of the brain and partially under genetic
control, that, therefore, this is a fixed, genetically mediated
biological deficit, which will be lifelong and unchangeable.
I will bet dollars to doughnuts, give odds to anyone around
the table who would like to take me up on this bet that if we do
research and show — use the approach that we have developed for the
children with ASD, where we help parents understand the unique biology
of the child and then we tailor the learning interactions to the
biology of the child. So a child, for example, who has got problems
with visual pattern recognition or auditory sound recognition, we
provide extra experience but in a fun way for that child while
we're mastering the milestones.
So we meet the child where he is. If he's not engaged, we
don't try to teach him words. We work on engagement. But we
do it in the context of the child's unique biology. So we're
extra soothing for the over-reactive child. We're extra energizing
for the under-reactive child. For the sensory-craving child, who
is impulsive and all over the place, we provide extra structure.
For the child, again, who doesn't decode visual input, we're
slower on the visual providing more auditory support or vice versa.
So we really tailor to the child's biology. That's
not intuitive. It's very rare, we find, that parents can do that
on their own. Occasionally some parents have figured it out just by
reading some of the materials.
But this is a relatively new approach represented by a group of
us who are not just using a fixed curriculum but tailoring the approach
to the child. So there are biological differences and we tailor.
What I would predict hypothetically, again, from a
hypothetical bet, is that if we looked at the mirror neurons for kids
who were deficient and then provide them an environment that had this
very tailored approach, we would see their mirror neurons, their
ability to imitate, grow.
And if we had another group that was given a more
conventional intervention for autism, let's say more of a
behavioral approach, just training, memory, and rote behaviors, not
working on the fundamentals, we would not see changes in their brain
In fact, we're doing just such studies now at York
University in Canada, where we have a big research grant, where
we're studying the brain as we're doing our intervention
programs, to see what happens inside the central nervous system, as we
provide the opportunity for children to master these milestones.
So I think that research on mirror neurons and other
neurobiological research is very exciting and very important except
there's often the assumption that it's fixed and can't be
altered by the environment. And that is an unproven assumption and a
mistaken assumption I think and a pessimistic one.
PROF. HURLBUT: You know, as I looked at that, the other
thing that struck me was you can imagine those parents getting pretty
frustrated and then kind of flooding over and causing things to get
worse. And I thought as I was watching that how often that must
actually be happening, both within the home and within school settings.
And it strikes me that from your description, there is such
a range of pathologies and normal chronologies as well as styles of
learning and so forth.
Are we doing a violence to our society by our standardized
education? Are we somehow missing the point in stigmatizing and
marginalizing certain people as failures?
I mean, Mike Merzenich is a very interesting guy to talk to
about dyslexia in his programs to technologically in a way overcome
this strange barrier to neurodevelopment. He has a program called Fast
Forward, where he uses computers to retrain the hearing discernment so
that they can then hear the language they weren't hearing before.
What strikes me is — and he will tell you that a great many of
the people in prison are actually suffering from dyslexia. And
you can imagine that we may have stigmatized them very early and
just essentially promoted their failure with our standardized system.
Would you comment on that? And also, in addition the kind
of thing Mike Merzenich is studying, what kind of technological things
can this Committee have on its radar for what interventions might be
done to improve the range of approaches that are causing some of these
DR. GREENSPAN: Yes. I think, number one, the answer is
yes, 100 percent. We are causing more harm than good with our
standardized approaches. Most children vary considerably from other
children in the way they learn. They react differently. We have shown
this now very well.
Even normal children have different patterns of reactivity
to sound and sight. They process sounds and sights differently.
Basically they have different strengths and different weaknesses, which
most parents know about their own kids.
And there is a cycle of failure when a child enters school with
processing problems, not the first kind of child who just needs
extra practice reading but the second child who can't decode
the sound and that is why he is not reading.
So, even with extra help in school, he is frustrated. He
is not getting it because he is missing the fundamentals. And we have
approaches that work on the fundamentals, that work on auditory
discrimination first before we expect them to learn to read that are
very successful, by the way.
Then we have evidence for their success. So it's not
as though we couldn't be helping them, but it requires better
diagnosis and individualizing the educational system.
When we don't do that and the child experiences failure
and also has families that are under stress, then there is a high
likelihood of school dropout. Then there is a high likelihood of
delinquency. Then there is a high likelihood of winding up in the
criminal justice system. And the rest is sad commentary.
We can intervene at many points in that developmental trajectory.
One of the points educationally is to teach that child the proper
sequence to reading and then also have better school-parent partnerships
so we pick up the stress at home. And even if we can't help
that family sufficiently because their problems are so grave, we
can provide more support at school for that child so that there
is a mentor program associated with the school so there is some
adult that the child can do well with.
We have learned that even kids from the most high-risk
environments who are given other adults to relate to may become the
policeman, rather than the criminal, you know, may have a different
identification and a different adaptation.
So the answer is a resounding yes. We are doing a terrible
job with our current system. And we're creating problems. And
it's the wrong philosophy. It has to be an individual variation,
individual different philosophy, not a one size fits all philosophy.
And your second question? Just remind me again a bit. I
got so focused on the first one.
PROF. HURLBUT: Are there other technological things we
should be alerted to?
DR. GREENSPAN: Yes. I think what we need to be most
alert to is that we now have the understanding. It's not based on
high technology. I mean, Fast Forward is a good example. I'm very
familiar with it. It's a way of helping kids processing. But it
also has its negative side because it increases screen time.
And a lot of these kids need more human-to-human interaction.
There are other ways to get the same processing improvements in
human-to-human interaction, where we get two for one. So depending
on the child, I may recommend it for some kids and not for other
kids, again, individual difference model.
So the technology that we need to be advocating is our new
knowledge base. We now have the knowledge base about what constitutes
healthy development. We have the knowledge base for early detection of
children who were not mastering these healthy milestones. And we know
better what kinds of experiences, some involving technology, some
involving human interaction and family support. And we need a
comprehensive, you know, family-oriented, broad-based approach.
There is a book I will send around that we just wrote called The
First Idea: How Symbols, Language, and Intelligence Evolved from
our Primate Ancestors to Modern Humans. And based on your
questions, I was going to send it before I came to the Committee,
but now based on the way the questions are going, I'll definitely
send it after having had a chance to meet some of you and hear your
questions because I think you'll find it interesting. It addresses
just these questions and issues you're raising.
DR. KASS: Very quickly. I would be willing to pass if
you want to move on, but, first of all, I very much welcome this
approach, which begins with an attempt to give an account of healthy
However, I am struck by the certain absence from this
account. It looks like an account of child development that would get
your kids into good schools and keep them out of the hands of
psychiatrists, where what is missing is something like the development
of habits and questions of character and impulse control, how to deal
with your fears, how to practice self.control, and just simple things
like toilet training, eating with implements, not interrupting, showing
respect for your elders, putting your clothes in the hamper, certain
kinds of elementary things.
And it seems to me that if a concern is probably triggered
through autism and things of that sort, I understand exactly why the
article goes the way it does. On the other hand, there are some parts
of child rearing which are like teaching young birds to fly and other
parts of child rearing are like breaking a wild horse.
And the question of vanity, pride, and self-esteem are at
the center of this. On the one hand, you want children to feel
self-esteem. On the other hand, you don't want them to become
little egomaniacs and think they're as large as the whole world.
And I would think that an account of mental health and normal child
development would have those characterological things because very
often it's the absence of that kind of self-command —
I'm not talking about high virtue but minimal virtue —
that gets in the way of people actually being able to learn.
DR. GREENSPAN: Absolutely. I'm glad you asked
this question. The approach we take to that — let me give
you an example just by talking about moral development — thinking
about it in a complex dynamic way or what I would call an over-reductionistic
An over-reductionistic way would be, unfortunately, the metaphor of
breaking the wild stallion. I think that's reductionistic.
You know, you've got to discipline the kid more. You've
got to scare them a little bit and teach them to be a good citizen.
I think that often doesn't work. It produces a fearful
person. It produces often a non.thinking person, often produces a
person if they have values, if they're very concrete, they often
break the values. They're the person who when you're watching
him does the right thing. But as soon as they're off in their own
place, they do the wrong things.
On the other hand, if moral development is based on the
healthy model of development, it starts with forming that relationship
with others because you have to care about others to be a moral person,
to be empathetic. You have to invest in relationships.
You have to be able to read the emotional signals of others, two-way
communication, to understand what another person is feeling, to
be a moral and ethical and empathetic person. And you have to be
able to be a complex problem-solver where you read patterns so you
understand other people's behaviors as well as your own and
how your own behavior is influencing theirs as part of pattern recognition.
Then you have to be able to use ideas to express your
feelings and also express to yourself the feelings of others. And you
have to be able to connect those ideas together logically.
Then you have to become a gray area thinker because if
you're an all or nothing thinker, you'll say it's either my
way or the highway. But if you're a gray area thinker, you'll
say, "Well, we've got to share. We've got to compromise.
You know, sometimes I get my way. Sometimes he gets his way."
And you become a reflective thinker if you're fortunate.
From an empathetic and moral point of view, that means you can understand
your feelings in relationship to other people's feelings and
also regulate your behavior accordingly.
Now, does limit setting play a role in that trajectory?
Absolutely. Will kids test the limits? Will they need punishment
sometimes? Absolutely. Will they need firm boundaries? Absolutely.
I have written 38 books. And you will see that in every
book I have written: the importance of the firm boundaries, firm
discipline. But it has to be gentle, supportive, and in a
thinking-based approach, where the child understands the reasons for
So it's not easy to do. It's not easy to produce a highly empathetic,
moral person of high character. And I agree with the thrust of
your comment that it does require the discipline in the boundary-setting
part of it, but it requires it in the context of the thinking-based
individual who is sold on the human race and who cares deeply about
other people. We have to have both.
And what happens if we get into polarized discussions, where there
is the kind of laissez-faire attitude, "Just let the kids become
narcissistic and unbridled," on the one hand, or the over-disciplined
approach, "Let's scare the shit out of them" but not
give them the nurturing that they need.
And neither approach works. One produces a fearful or
antisocial person. The other produces a narcissistic person. So I
think neither one works in isolation. I think both.
So the thrust of your comments I agree with.
DR. ROWLEY: I was going to just
ask you about the wider acceptance of some of these views in other
either school systems or medical/child care settings, though I realize
that we're more than out of time. Maybe you could comment briefly.
DR. GREENSPAN: I think what we are doing is we're
trying to educate colleagues in schools, in child care settings, day
care, also parents, but we're fighting a very powerful trend in our
culture in the other direction. There is a very powerful trend in
education towards rote memory approaches, not thinking-based
There is a powerful trend for families, even when they can
provide high-quality care, to farm out the care to day care and, as you
heard, even in the psychiatric community, you know, a tendency to look
So there was momentum in this direction in the 1960s and
early '70s towards more dynamic what I would say frameworks. And
there has been a regressive movement in the last 30 years or so. And I
think it's very important to counter that now with a progressive
movement towards understanding the complexity of human development.
So we can modify the philosophy-guiding, education-guiding, child
care-guiding-related approaches. And I think a Council such as
this in terms of setting a broad tone, having a statement about
what constitutes human functioning, and all the elements that have
to be taken into account, and focusing on the theme you were saying
related to individual variation, I think having some sort of official
support for our concept of humanity so we don't — if we're
moving dangerously towards an automaton computer-based picture of
the human brain — I'll just say one more thing, I know
we're out of time.
I talk with my neuroscience colleagues, many of them
distinguished. But even in that time, like the mirror neuron
research. It's a very modular view of the brain. We've got
this area of the brain that's happiness. That's controlled by
this gene. We've got this area of the brain that's pride and
avarice. It's controlled by this gene.
I mean, that's just not true. It's not proven.
It's a scary science fiction image of a computer, not a human
being. Human beings function in an integrative whole. And all the
parts of the brain interrelate to one another. But we're
dangerously moving in that direction.
That's why we pop pills for every ailment from frustration
to bad behavior and why we're putting kids on medication younger
and younger. So if you want to attack the problem from the core,
we've got to do it with the definition of what constitutes healthy
human functioning and how that has to modify our education, mental
health, and child care approaches.
CHAIRMAN PELLEGRINO: Thank you very much.
DR. GREENSPAN: Thank you.
CHAIRMAN PELLEGRINO: There is never enough time.
DR. GREENSPAN: Yes. Well, thank you all. And it's a
pleasure to be talking with you.
CHAIRMAN PELLEGRINO: Really appreciate it. Thank you.
DR. GREENSPAN: Thank you.
CHAIRMAN PELLEGRINO: I think we will move right to our —
DR. FERNETTE EIDE: If you need to stretch your legs, go
PROF. MEILAENDER: Before they start, could I just sort of
make a comment/question? I am just afraid that they are going to try
to rush through what they have. And I think we should agree right now
that we're staying longer than we planned to.
CHAIRMAN PELLEGRINO: Yes. I will do that.
PROF. MEILAENDER: I don't want them to try to say in
15 minutes what they were going to take a half an hour to say or
something like that. I'm content to stay.
CHAIRMAN PELLEGRINO: Full agreement with that.
DR. FERNETTE EIDE: You're so kind. Thank
PROF. MEILAENDER: Most people don't think that.
DR. FERNETTE EIDE: We will try to make it really good.
Yes. We will try to make it really good. Otherwise we'll get out
the hook. Okay.
Well, thank you very much, Dr. Pellegrino and members of the Council,
for the honor of inviting us here. Given our background and our
clinical focus, our comments today will deal with the needs of school-aged
children, particularly in regard to how we as a society choose to
understand and treat their learning behavioral difficulties. I
think it's a nice dovetail with what Dr. Greenspan just spoke
When we first began working with children with learning and
behavioral difficulties, we were struck by a paradox that existed in
this field. Although we found many different professional groups
willing to diagnose and treat such children, general and developmental
pediatricians, pediatric psychiatrists, psychologists,
neuropsychologists, educational specialists, and even a few
neurologists, we found a surprising degree of uniformity in the
approaches that they employed.
Each specialty relied almost exclusively on behavioral
approaches to diagnosing and managing children's learning and
behavior problems on observing and categorizing children's
behaviors, rather than identifying the causes of those behaviors in the
child's unique neurological wiring and life experience. In
practice, this meant a reliance on the DSM. And it's exclusively
As a neurologist, this pattern of assessment went very much against
my grain. I was trained never to rely exclusively on behaviors
for diagnosis because behaviors, like limps or clumsy fingers, can
have many different causes, as can problems with reading or paying
attention. Instead, we're taught to work backward from behaviors
to locate specific causes in the nervous system because effectively
directing treatment requires correctly identifying the sources of
The DSM, by contrast, bases diagnoses and treatments
exclusively on visible behaviors and ignores their causes. The
distinction between behavioral and causal approaches is important
because the decision to adopt one approach or the other has profound
consequences for how we understand and treat children with behavioral
and learning challenges and for how we organize our educational, health
care, and even parenting practices.
Consider, for example, how this decision affects our
approach to children who demonstrate the behaviors in the DSM's
ADHD diagnostic scale and are having difficulty paying attention in
This is a very large group of children. According to the
American Academy of Pediatrics, 8.10 percent or up to 14 percent of
boys will meet the criteria for ADHD.
Now, given the Council's previous works, we believe
you're largely familiar with the DSM's approach. So we're
going to focus here on the implications of adopting a causal or
neurological approach to children with attention problems with
reference to how such an approach can serve as a model for approaching
children's learning and behavioral problems in general.
A causal approach would begin with the premise that
children can show ADHD-type behaviors for many reasons. Most children
who struggle in school frequently show some of these behaviors and will
meet the criteria.
Studies have also show that nearly all children stop paying
attention when they're confused and become unmotivated when they
can't succeed. Confused and unmotivated children are often
inattentive and restless. And it's important to distinguish causes
When we examine children who show ADHD-type behaviors, we often
see a variety of causes for these behaviors, rather than a single
global problem with attention. Many have undiagnosed reading and
handwriting problems or brain-based visual or auditory processing
deficits. There are sensory-motor processing problems that can
make handling the barrage of information in a busy school environment,
including social signals, difficult.
Also, we find children with strong or uneven learning
preferences whose performances might vary dramatically depending upon
the learning environment. There are also highly intellectually gifted
children who may be simply bored with an insufficiently challenging
Understanding why a particular child is struggling with
attention involves more than simply documenting behaviors. It requires
completely assessing physical, medical, neurological, cognitive,
behavioral, emotional, educational, and psychological aspects of a
child's development to see where breakdowns in a child's
attentional or behavioral control mechanisms are occurring.
Although many practice guidelines, like the American
Academy of Pediatrics', advise considering such factors when making
behavioral diagnoses, they provide little guidance on how they should
influence the diagnosis. And because they are not included in the DSM,
researchers have documented that they are seldom considered by
practitioners when diagnosing ADHD. Yet, these factors play a crucial
role in determining a child's problems with attention and behavior
and must be identified if the right steps are to be taken.
School or day care for younger children plays an enormously
important role in children's neurological and behavioral
development because most children spend so much time there.
For many children, schools are sources of enormous stress.
Stresses may arise from interactions with peers involving struggles for
acceptance or esteem, or even physical threats or bullying, or also
with teachers, who are enormously important figures, especially during
the elementary years. Stresses may also arise from the learning
Academic pressures have intensified in recent years due to
the standards movement. While valuable in pointing out the problems
with our current educational system, the No Child Left Behind Program
has, with an almost Orwellian irony, raised the specter of grade
retention and failure for millions of children.
One recent survey of third graders preparing to take a new state-mandated
test found that 80 percent ranked their stress levels as "high"
or "very high." When asked about their greatest fear,
the most frequent response was, "I'm worried that my friends
will think I'm stupid if I fail."
Unfortunately, for all too many children, this fear
isn't idle. Enormous numbers are struggling to meet basic academic
standards in areas like reading, writing, math, and language. Many
have neurologically based disorders of cognition and learning.
Up to ten percent of children have dyslexia, 18 percent with untreated
visual problems, 13 percent partial hearing loss, 5 to 10 percent
with central auditory processing disorders, 5 to 10 percent language
disorders, and 6 percent with motor coordination problems that impair
vital functions like writing.
Unfortunately, current federal guidelines permit only 3
percent of a school's students to opt out of standardized
assessments because of disability. So many students with learning
problems are under increasing pressure to meet performance standards.
Most learning or behavioral difficulties arise from one of two types
of problems. The first is a problem with one of the basic neurological
functions that underlie reading, writing, counting, and these other
basic academic functions. These neurological problems, which occur
in areas like perception, motor coordination, memory, attention,
or pattern processing, are often very difficult to diagnose because
they frequently don't present in ways that suggest their true
nature. Yet, these difficulties are relatively common in school-aged
children, and are often mislabeled as deficits in attention or in
autism spectrum disorders.
Correct diagnosis is crucial because, as we'll discuss
later, these problems can often be treated successfully using therapies
that take advantage of nervous system plasticity to repair the
underlying deficit and eliminate the resulting ADHD-type behaviors. We
will be talking about some of the technological things as well.
The second type of problem is caused or greatly exacerbated
by instruction that is poorly suited to the way that particular
children are wired to learn.
While most of us learn better in some ways than others, for
some children these differences are profound and are essential to take
into account when designing their education.
These children could learn very well in the right setting, but they
struggle in particular classrooms because information is presented
to them in forms they are not well-suited to take in or process.
They are asked to express themselves in ways that hinder them from
fully communicating their ideas.
Frequently, these children have difficulty taking in information
through auditory-verbal, or lecture-based, instruction or expressing
information through writing by hand.
Because our educational system overwhelmingly stresses these forms
of communication, children with these primarily visual, spatial,
hands-on, or novelty or experience-based learning styles or difficulties
with written expression can suffer needless problems with learning
Some children also differ markedly in the rate and depth at
which they prefer to take in information. Some are intellectual
pythons, who prefer extended periods to digest a single topic. Others
are learners like sparrows, who need frequent short bursts of learning
interrupted by frequent breaks.
While all students must achieve certain basic competencies
in core subjects, they do not all need to pursue them in the same ways
or through the same routes. What they really need is a form of
education that's right for the children who learn the way they do.
In most cases, these learning differences don't need to become
disabling unless we let them. Many children who struggle in school
do not have cognitive impairments or abnormalities in any absolute
sense but simply differences in learning style, many of which actually
render them well-suited for various adult occupations.
So we wanted to give you some examples from our clinical
practice. Because our clinic is located just north of Seattle, we see
many children who are the kids of software designers and engineers who
work for companies like Microsoft and Boeing.
Often the supposed learning disorders that have made these children
poorly suited for auditory-verbal learning environments in their
schools are manifestations of the same visual and spatial reasoning
styles that have made their parents professionally successful and
creative. Their learning and behavioral problems simply result
from the conflict between learning style and their school's
Such conflicts can be avoided by providing children with as
many routes to learning as there are different types of learners and
thinkers. Our adult society thrives on the differences between
learning and thinking styles, interests, and work habits that produce
teachers and soldiers, engineers and plumbers, lawyers and graphic
artists, doctors and cosmetologists. Yet, our schools treat this
diversity as a problem to be solved.
The cost of failing to meet the needs of children with
either of these two types of problems is enormous, both in human
suffering and in squandered talent.
When children find themselves in environments where
learning is demanded but not facilitated, they all too often end up in
a cycle of despair. They struggle, fall behind their classmates,
become anxious and ashamed of their difficulties, and even of
themselves. They may even have begun to wish they had never been born,
like our patient who told her mother that she wanted Santa to bring her
death for Christmas or the boy whose mother found in his backpack a
note he had written to himself saying he deserved to die for being so
For children like these, learning challenges aren't
just a question of grades or achievement. They strike at the very
heart of a child's self.image and for some can quite literally be a
matter of life and death.
Too often they receive a variety of diagnoses, like ADHD,
oppositional defiant disorder, depression, conduct disorder, bipolar
disorder, and a variety of drugs, often three to four in a single
child, to control behavior.
Is this the best we can do? The answer is unquestionably
no. To help these children develop into competent and confident
adults, we must identify the true causes of their behavioral and
learning problems and equip their parents, teachers, and the students
themselves to address these causes directly, rather than simply
medicating troublesome behaviors.
To meet their fundamental needs for learning and development,
we need to shift our focus beyond mere behavior, toward what modern
neuroscience is telling us about the different ways that different
children learn and process information and the ways in which their
minds can be developed through targeted experience.
By using these insights, we can ensure that each child is
able to master the skills that he or she needs not only to survive
their education but to thrive in the demanding world of the future,
where simply behaving by the rules will not guarantee success.
DR. BROCK EIDE: To reach these goals, we must first
remove the barriers to progress that have been raised by the behavioral
and medication-dependent approach in at least four areas.
First, in the area of research, in the field of attention,
for example, although the ADHD model has laid claim to scientific
consensus, it has continued to receive criticism both from inside and
outside the research and clinical communities. Supporters of the
behavioral approach have responded with a vigorous defense of the
validity of the ADHD diagnosis and the efficacy and safety of stimulant
treatment in a manner that has inhibited research into the
heterogeneity of attention problems, enforced the notion that all
children with attention problems suffer from the same general disorder
of attention, and impeded research into treatments.
For example, despite decades of heavy stimulant use, there has still
never been a good long-term study of their safety and efficacy.
The only large study so far into risk factors for persistence of
ADHD from childhood into adulthood by Kessler, et al., which we
had included in your briefing book, found that after controlling
for symptom severity before intervention, the single factor most
predictive of persistence was treatment for ADHD as a child. Treated
children had an almost five-fold greater risk of persistence.
Given the virtual absence of data regarding long-term
consequences of therapy, the growing practice of treating children with
stimulants, antidepressants, and even antipsychotics continues as a
vast untracked experiment in clinical neuropharmacology on an
absolutely unprecedented scale.
A second area where this behavioral paradigm has inhibited
progress is in clinical diagnosis and treatment. Unsurprisingly,
schools and day cares are the leading catalysts for diagnosis.
With ADHD, in nearly 60 percent of cases, teachers are the first
to suggest the diagnosis, though many teachers over-identify children
at risk. In one study of teacher perceptions, 72 percent of teachers
identified over 5 percent of students as having ADHD, and fully
one-third identified between 16 and 30 percent. Importantly, those
rates of identification increased with class size.
Placing teachers in the role of diagnosticians creates a
difficult dynamic, in which parents often feel pressured to pursue
formal diagnosis and initiate drugs. If pills make children more
compliant, yet parents refuse to use them, hard feelings can ensue.
In our clinic, we've heard from many parents who have
been told by teachers or other school officials that a refusal to place
their child on stimulants would result in harm, both to the child's
education and to the classroom environment.
Although legal protections have prevented the most overt
forms of coercion, teachers still hold considerable authority and
function as gatekeepers to success through their abilities to assign
work, provide grades, and recommend retention.
Problems with diagnosis and treatment are also seen in
physicians' offices. Studies have shown that in over half of cases
where primary care doctors make the diagnosis of ADHD, they do so
without following established guidelines or formally assessing the
One community-based study of children receiving stimulants found that
over 40 percent had no documented diagnosis of ADHD. Another study
found that in roughly one-quarter of visits in which a psychotropic
medicine was prescribed, there was no associated mental health diagnosis
in the patient's chart.
To be fair, primary practitioners face a difficult situation. Most
are not trained in alternative approaches to attention problems,
and many feel short of other options. Meanwhile, they are expected
to do something to solve the child's problem within the confines
of a ten-minute appointment.
Similar problems can also occur in the area of autism and
autism spectrum disorders. One paper included in your briefing packet
showed how Department of Education statistics for autism were
compromised by variations in state definitions for autism.
Oregon, for example, lists autism criteria as simply,
"Impairments in social interaction." So defined, autism is
little more than oddism, and any child who differs from peers can be so
labeled. Predictably, Oregon has had the highest rates of autism in
the country, two to three times the national average, since statistics
were first kept in the early 1990s.
Now, this is not in any way meant to cast aspersions on the
diagnosis of autism, which is a legitimate pathophysiologic entity, but
it is meant to point out how diagnoses made primarily on the basis of
behaviors often undergo a process of diagnostic mission creep, in which
after establishing a beachhead in an area of true impairment, they are
extended by analogy to include a much greater range of behaviors of far
less severity until they shade imperceptibly into normal.
An additional source of difficulty arises when pressures
faced by schools and physicians combine to create incentives to label
children with behavioral diagnoses.
The IDEA and its recent amendment have effectively tied
school services and insurance payments to a limited set of funnel
diagnoses, like ADHD and autism.
Disabilities in reading, math, language, and writing are
lumped together under the heading "specific learning
disability." And amazingly in many districts these so-called
academic disabilities will not qualify a child for an individualized
educational plan while so-called medical diagnoses, like autism and
Two results follow. First, there is often pressure to
diagnose a child with ADHD or autism simply to access needed services
or accommodations for a learning problem.
We had two cases just like this just last week. One mother
of a fourth grade girl with classic dyslexic reading difficulties and
handwriting difficulties was told by the district that they didn't
recognize dyslexia as a disability, but if she could get her daughter
diagnosed with ADHD, she could have access to the same services. This
is a ridiculous way of handling diagnoses and children.
The second unwelcome result is that teachers receive
lopsided and incomplete training on the nature of children's
learning challenges because their education is geared to the current
Autism and ADHD receive star building, while more common
disorders, like dyslexia or handwriting impairments, often receive
little explicit coverage. Consequently, teachers often tell us that
they have little idea how to adjust their educational strategies when a
student struggles other than to refer him or her to a learning
Unfortunately, many learning specialists and school psychologists also
receive little training in brain-based cognition and neurodevelopment
and often follow general, rather than individualized, approaches
to helping struggling children.
All of these factors combine to funnel growing numbers of
children into behavioral diagnoses and onto psychotropic drugs.
Between 1994 and 2001, psychotropic drug prescriptions soared for
teenagers by 250 percent. By 2001, one in every ten office visits by
teenage boys led to a prescription for a psychotropic drug.
In his testimony before this Committee, Dr. Steven Hyman
speculated that much of this explosion has been driven by inadequately
trained primary care practitioners who aren't following guidelines
While this unquestionably contributes, if it were the major
driver, we would expect to see many children who had been placed on
medicines by primary practitioners taken off them by psychiatrists and
But we very rarely see this. Instead, specialists
typically switch or even add medicines. Although primary care
practitioners may sign the majority of prescriptions, they appear to us
to be reflecting the practices of the specialist practitioners they are
It's difficult to see how this problem can be resolved
simply through continuing medical education when over half of the CME
in the US is funded by drug companies.
A third place where behavioral dominance is inhibiting progress is in
the area of the moral development of children. The article in your
briefing books from the New York Times on psychotropic self-medication
in young adults entitled "Young, Assured, and Playing Pharmacist
to Friends" is obviously not a formal study, but it does offer
some important insights into the kinds of habits that can be engendered
in children who grow up taking behavior and mood-altering drugs.
One young adult, for example, was quoted as saying "I
feel like I have been programmed to think, 'If I feel like this,
then I should take this pill.'" Notice both the passivity and
the sense of mechanism in the phrase "have been programmed."
These feelings mark the transfer of causal efficacy from will to pill,
where the role of the will is reduced to the agent that picks the mood
and selects the drug to reach it.
This is a considerable decline in the will's domain and
a reminder that other things may be lost when control of troubling
behaviors or moods is pursued through chemical shortcuts.
Drugs don't teach self-awareness, self-restraint, the ability
to delay gratification, persistence, resiliency, or any of the other
skills that children need to control their own behavior. Yet, developing
these traits is one of the crucial missions of childhood.
We should take these challenges very seriously if our goal
is to help children develop into competent and productive adults and
not simply to control their behavior.
This brings us to the fourth and final area in which the
dominance of the behavioral paradigm has inhibited progress, and
that's in relationships of adults with children.
Behavioral labels can dramatically affect how adults
perceive and behave toward children by purporting to describe
limitations in their abilities, feelings, personal will or agency, and
We've had many parents tell us how teachers or therapists
after casually diagnosing autism have made sweeping pronouncements
about their child's cognitive and emotional limitations, like
the speech therapist who told one mother that her son's apparent
maternal attachment to her was not true affection because he had
Asperger's syndrome or the many teachers who ascribe the intense,
advanced, and often specialized interests of highly gifted children
to the perseveration of autism or the hyperfocus of ADHD, rather
than seeing them as healthy manifestations of high intelligence.
Diagnostic labels can also diminish a sense of adult
responsibility for helping children with behavioral problems. They may
convince parents that their children can't control or prevent their
misbehaviors, which only feeds into the cycle of bad behavior.
For example, we failed to convince one highly educated and professionally
successful couple that their son, who had been diagnosed with ADHD
and Asperger's syndrome, needed to be disciplined for repeatedly
trying to shut his younger sister's head in a door, rather than
simply to have his meds adjusted. Such a view limits both children's
and adult's responsibilities.
If the behaviors are the result of a disease and the pills
make the behaviors go away, then the scope of adult responsibility
shrinks to providing the right drugs, rather than disciplining,
training, or modifying the home or educational environment.
Teacher's, too, often find it easier to attribute
inattentive or hyperactive behaviors to ADHD than to look for learning
challenges that require special educational modifications.
Although we can't show a causal link, it's worth noting that
there's been a dramatic and well-documented decline over the
last several decades in educational intervention research while
psychotropic use has skyrocketed.
Finally, the diagnostic and treatment practices that have
arisen as a consequence of this behavioral model both raise and obscure
important questions regarding the extent to which adult approaches to
children with behavioral and learning problems are really beneficial to
the children themselves and to what extent they are simply convenient
One of medicine's most basic ethical principles is that
interventions can usually be justified only when they primarily benefit
the patient. How does such a consideration affect, for example, the
use of stimulants in ADHD?
In the case of children whose behaviors are so severe that
they have difficulty functioning in any environment, a group most
experts would place between two and three percent, the benefits of
treatment are easier to cite: improved relationships, fewer risky
behaviors, et cetera.
Treatment with stimulants can sometimes produce dramatic
effects in these children, though even in this group, it is worth
noting that behavioral modifications can also be effective and there
are also significant subpopulations of children in this group with a
history of head trauma or prenatal exposure to drugs for whom
medications are not at all effective.
In the much larger group of children whose functional
deficits are less severe, the benefits of stimulants are less clear.
One benefit frequently sought is improved academic performance.
Most parents and teachers believe that stimulants can make children
better learners. However, data supporting long-term academic benefit
is extremely thin.
In the MTA trial, scores on achievement tests were virtually unchanged
by stimulants. The sole demonstrable benefit, a one-point rise
in a reading achievement test, is comparable to a one-point rise
Although stimulants often do make it easier for children to
stick with and finish assignments, they don't make them better
readers, mathematicians, or historians. Stimulants help children
conform better to the schedules and activities they're assigned but
not to perform better in the sense of measurable long-term gains in
For many parents and teachers who have grown weary of
scolding, cajoling, and wrestling, this can seem like a big victory,
but the question is, a victory for whom?
The other key factor in determining the risk/benefit ratio
is risk. And for the reasons we've mentioned above, this factor
can't clearly be established at present.
In all but the most severely affected children, the
benefits accrue largely to others while the potential risks and the
clear short-term side effects accrue entirely to the child.
In such a setting, "Do no harm" should be given
more weight than it is. At the very least the medical community should
be more open in providing parents with a complete and accurate
assessment of the realistic benefits and the uncertain risks these
drugs may cause.
Although chemical states in the brain do influence behaviors and moods
and drugs can influence these chemical states, it's also true,
as we have heard from Dr. Greenspan, that non-medicinal interventions
can also alter brain chemistry and behavior in desirable ways.
Unlike medicines, which largely work only as long as taken,
changes induced by new habits, new ways of thinking, and new ways of
behaving really do become part of a child's neurological and
behavioral fabric and are generalizable to many activities.
This brings us back to the question of the fundamental
needs of children. One overwhelming need is an approach to education
and development that works with, rather than simply on, their
developing nervous systems.
In contrast to the behavioral approach, whose disconnect with causation
leaves it dependent upon the promise of better living through chemistry,
a more neurologically based approach holds out the promise of better
chemistry through living; that is, better neurological development
and function through targeted experience or experience-directed
The brain possesses a remarkable capacity to rewire itself
in response to experience. By carefully targeting inputs through
teaching, therapy, or play, existing brain pathways can be trained to
function more smoothly, old blocks can be bypassed and new learning
pathways can be developed.
By breaking down complex behaviors, like reading,
listening, or paying attention, into component functions, then training
those functions through targeted experience, researchers have
dramatically improved function in the complex activities.
For example, Klingberg and colleagues in Sweden have
significantly improved working memory and reduced ADHD-type behaviors
in children diagnosed with ADHD using a computer-based training
program. And in children with reading difficulties who are often
diagnosed with ADHD because of difficulties listening or concentrating
on visual materials, researchers like Harold Solan at the State
University of New York and Michael Merzenich at UCSF have shown that
children can improve their reading skills by intervention that improve
visual attention and auditory discrimination.
Work like this should lead us to abandon the view that
children with learning and behavioral challenges are simply deficient
in various brain functions or chemicals and see them, instead, as
needing new experiences that can help them learn and function in new
What we are arguing for is an approach we call
"positive neurology," in analogy to the positive psychology
movement that has shifted this field's emphasis from the relief of
mental illness toward pursuit of mental health.
A similar trend in neurology, which aimed beyond cataloging
weaknesses to developing strengths through targeted therapy, could
revolutionize our approach to struggling children.
A child's brain is remarkably resource-full because of its plasticity
and its diversity of systems. That's why most children with
learning and behavior problems can be greatly helped by reshaping
their experience, both in the sense of general environment and in
the therapeutic sense of targeted experience, to optimize performance
and develop new capacities.
Our obligation to children is not simply to stimulate or
sedate them so they can conform to the demands of a system that is not
well.suited to their learning and their developmental needs but to
create a system that better promotes development.
To accomplish this, our schools and our society's
parents must develop a more neurologically informed understanding of
the diversity of childhood development. While all children must
acquire certain necessary skills and essential knowledge, the
experiences they need to acquire them will differ from child to child,
both in nature and in the rate and manner of delivery.
Children differ markedly in the ways and rates at which
they develop. And a given child's development may differ greatly
in different areas. That's why attempts to educate all children in
the same ways and at the same rates result in so many learning and
There's no reason to assume that all children should
make identical progress in all subjects using identical approaches, nor
is there any reason why a child should be prevented from making
additional progress in one area, like math, because he is not moving as
fast in another, like reading. Yet, these are standard assumptions in
most of our schools.
Failing to take neurodevelopmental variations into account in
designing schools means many children suffer needlessly because
they're developing in ways or at rates that are poorly suited
to a one-size-fits-all education.
It's as if our schools had adopted a factory farming
model, where cacti and orchids were treated just like potatoes. No one
would try to raise plants with this model, and it works no better with
Younger boys are particularly likely to be disadvantaged
because auditory processing and motor delays are much more common in
males and often present as difficulties in attention.
One-third of five and six-year-olds cannot process a sentence
longer than nine words. So all that's retained from "When
you need to go to the restroom, raise your hand and wait until I
call on you," is "When you need to go to the restroom."
It's easy to see why such children can appear impulsive or inattentive.
Likewise, children with sensory-motor delays who require frequent movement
to stay attentive may suffer learning and behavior problems when
classroom schedules require lengthy seated work.
Schools must recognize that children develop at different
rates and in different ways. Rather than trying to modify them to fit
arbitrary educational frameworks, we should design our systems to
promote healthy neurocognitive development for children with all sorts
of learning and processing styles.
There is no one right educational approach for all
children. And trying to design our systems as if there were will
inevitably cause difficulties.
One key area in which a more neurologically appropriate
understanding is needed is in the concept of basic skills. When we ask
educators, "What are basic academic skills?" most cite
memorizing the alphabet, learning letter sounds, counting, performing
simple calculations, and mastering penmanship.
In reality, these academic skills require complex mixtures of
many underlying functions. Before children can master ABC or 123,
they must first master even more basic neurological skills, like
auditory discrimination; speech-in-noise perception; visual perception;
sensory motor skills; memory and language skills; and attention-related
skills, like mental focus, motivation, and impulse control.
Normally, these skills are developed through interactions
with parents, siblings, and peers, but for some children, like those
Dr. Greenspan talked about, often who have impairments in sensory
inputs or in the connections that integrate brain functions, routine
play may be too confusing to stimulate optimal development.
These children must have their needs specifically assessed
so lagging functions can be developed through the use of targeted
experience or therapy. For most children, this will involve the use of
highly structured play activities, where incoming patterns are
simplified for easier processing and repetition is used to enhance
retention and increase the possibility of new associations.
In the future, older children, in particular, will benefit
tremendously from a continuing breakdown of the artificial barriers
that divide play, education, development, and therapy.
Both schools and therapy centers would benefit from an
increasing use of technologies that allow sensory inputs to be
precisely and repeatedly delivered, feedback to be immediate and
direct, and progress to be monitored, not only by therapists and
teachers but also by the children themselves.
This is one area where government can play a vital role by
bringing together experts in education, neurocognitive development, and
the software and video game industries to discuss ways in which healthy
neurocognitive development can be promoted through educational,
therapeutic, and entertainment programs.
We are already beginning to see games that were developed
purely for play that can be used therapeutically to improve mental
focus, impulse inhibition, and motor control in ways that generalize to
academic skills, like the popular Dance, Dance Revolution, where
children imitate movements on a screen by dancing on a pad that
registers their movements.
By intentionally promoting needed skills, companies like
Electronic Arts, Nintendo, Microsoft, and Sony could promote skills in
behavioral control undreamed of by Pfizer and Merck.
Another way to promote healthier neurocognitive and
behavioral development is by providing a greater degree of
individualization in the learning experience. Basic neurological and
academic skills can be acquired in many ways. And ideally each
child's instruction should be tailored to make use of his or her
optimal learning style.
The key to individualization is providing incremental
challenges that are adjusted continually through ongoing assessment.
Research on motivation has shown a crucial relationship between success
in learning tasks and continued motivation. When children fail to
achieve a critical ratio of success, motivation plummets, and they
simply stop trying.
Children are often diagnosed with attention problems when
they give up on tasks where they believe they can't succeed, like
reading, writing, or math.
After repeatedly facing challenges that demand unmakeable,
rather than incremental, leaps in their exercise of skill, they simply
lose heart and give up. But even thoroughly discouraged children can
be rejuvenated by success.
We often see children who have given up in school work hard on demanding
remediative therapies once they've seen how small successes
build in a step-wise fashion. Success breeds success by developing
a taste for mastery.
Research has shown that mental focus increases dramatically
in children who have been diagnosed with ADHD when they're given
meetable challenges and deteriorates both when the challenges are
unmeetable or crucially not challenging enough. The desire to achieve
mastery is natural. Apathy is learned.
In summary, children need educational and clinical
approaches that work to support their neurocognitive development in
ways that develop their strengths and minimize their weaknesses, not
approaches that attempt to stretch and trim them to fit artificial and
The development of a child's mind is a kind of
unfolding or flowering that we can't wholesale create but which we
can nurture into fullest bloom. The metaphor is the garden, not the
factory farm and certainly not the neurochemist's laboratory.
While we neither could nor should seek to eliminate all
adversity from our children's lives, we should seek to create ways
of raising them in which challenges and struggles result in growth and
development, not frustration, misbehavior, diagnoses, and drugs.
CHAIRMAN PELLEGRINO: Thank you, Dr. Eide and Dr. Eide.
CHAIRMAN PELLEGRINO: Are there questions? Dr. McHugh?
DR. MCHUGH: Can I just make
one point? Obviously I'm not going to repeat what I said before.
You are beating on an open door with me. And until we change the
general direction of the American Psychiatric Association so that
in 2011, we don't have DSM-V, son of DSM-IV, son of DSM-III
— if that happens, it will be a disaster for American medicine
and for all the people. Okay? You should be screaming about it.
I'm screaming about it. And we'll all scream.
But I can tell you it's not likely to make any
difference because institutional psychiatry at the moment has this in
its bit. Bob Spitzer and everybody else says the following. This is
the central dogma of contemporary psychiatry. We do not know the cause
of any psychiatric disorders. Okay? That's the central dogma.
And it is amazing to hear it read out that way and produce this
imitation of Roger Tory Peterson.
Now, the second point I want to make, though, to you is
that everything you said today is wonderful to hear, but I heard it and
everybody heard it a long time ago. In what way are you different from
Itard; Seguin; Gallaudet; and, of course, the wonderful Maria
Montessori, who said all the things that you have said, not in quite
the task that you said it in but said it in exactly the same way, the
incremental learning, the differentiation amongst children, the
children learning at their own rate, all of that? Don't you agree
with me or do you?
DR. BROCK EIDE: Well, I think there's a few things to
say on that. Number one, I think the neuroscience is starting to catch
up with the —
DR. MCHUGH: With Montessori.
DR. BROCK EIDE: — with the political perception, yes.
DR. MCHUGH: She was wonderful.
DR. BROCK EIDE: You know, and empiricism and basic
research are basically the two hands that go together that need to
accomplish any subject. Hopefully the impetus from showing where some
of the research is heading can help to move that along in a policy
I think, you know, another way that the setting is somewhat
different now is that we're unquestionably in the midst of a crisis
in education that is universally recognized and that is not going
anywhere very soon.
I think that, you know, we made the little comment about
the No Child Left Behind policy. Some good things have come out of
it. I mean, it certainly made a lot of extra work for us, but it's
also helped to really strip away any pretense that there is no crisis
DR. MCHUGH: I see.
DR. BROCK EIDE: And it has put a sense of urgency, I
think, on, you know, the state educational associations and the
teachers that we talk to. They're starting to feel under the gun.
And I think that we're going to be able to see a
willingness to try more variations within the public school system than
we have seen before. So I think that is different.
DR. FERNETTE EIDE: I think that the internet also has
affected things. We get a lot of parents who are really combing the
internet looking for answers. And, in fact, there have been a number
of papers sort of actually ruing the fact that parents are trying to
end the drugs as soon as they can after they have been on it.
And I think there is a lot of interest and there are a lot
of people who are also really fascinated by the neurobiology and the
fact that functional imaging gives us a much better view in terms of
what is happening with learning disabilities as well as why kids'
brains are so different from adult brains.
So I think all of these kinds of things are swirling
influences that can lead to a discussion on a deeper level.
DR. MCHUGH: Well, I will be happy with the deeper
level. But the practices are all the same, as I said, from Itard
through Seguin to Gallaudet to Montessori. They are not different.
DR. FERNETTE EIDE: Well, I will tell you one thing.
DR. MCHUGH: And I want to know in what way. But I
might be missing something.
DR. FERNETTE EIDE: Yes.
DR. MCHUGH: I mean, I love this neurobiology.
DR. FERNETTE EIDE: Yes, yes.
DR. MCHUGH: I've got my friend here, who tells me
it's the greatest. But I want the psychology to do the thing.
DR. FERNETTE EIDE: We have been telling stories here
today. I have noticed that. So let me tell you a story.
DR. MCHUGH: Okay.
DR. FERNETTE EIDE: All right. Well, there was an
epiphinal case for me, actually, when I was asked to see in the
hospital a woman with juvenile diabetes and clearly an intelligent
woman. It was one of these kind of hopeless things. She's
complaining of memory problems, probably nothing we can do.
When I went to see her, it looked hopeless because she did
the digit span. The notorious thing for neurologists is, can we escape
diagnosis and adios? That is what we are trying to do.
DR. MCHUGH: That's right, yes.
DR. FERNETTE EIDE: But the interesting thing for me was
that she said she could only remember, actually, two digits. She
couldn't remember two digits in reverse. She could remember two
And she said, you know, "My daughter starts talking to
me, and I cannot even keep in the conversation. Once she starts
talking, I can't remember the beginning of the conversation. It
And then I thought, well, this is an interesting
situation. I wonder if this would help. She was a juvenile diabetic.
And she had become blind. But I saw all this fascinating work about
visual imagery. So she had acquired blindness. She was not
DR. MCHUGH: Yes.
DR. FERNETTE EIDE: So I said, "Well, I'm going to
give you the digits. And now visualize them in your head. It's a
much more diffuse network, actually, than actually just reading."
And so I said, "Well, now try to do it." She could keep six
in her mind with visualization. I thought, you know, "What
have we been doing all this time?" You know, why don't
you have a situation where you actually see someone who is aware
of how the brain is constructed and you say you have a block and
then you problem-solve and try to figure out around it?
We have a lot of psychometric exams where you have a
standardized battery. You can't go any other way. We've
taking a lot of the tools, for instance, like Mel Levine, where he
gives you a lot more flexibility when you administrate the tools.
So if we see a kid who has a block, a real bad block in
anything, we try very hard to find a way around it. And that's a
different approach to taking neurodiagnostics. And our hope is that,
actually, it becomes much more popular because it's using all this
latest research but, really, for a much better purpose.
And I think that, really, it certainly transformed our way
of thinking about things. And there's much more tools than you
CHAIRMAN PELLEGRINO: Meilaender and Foster.
PROF. MEILAENDER: Thank you very much. This was very
helpful and interesting to me.
I just want to make two comments. These are not really
questions. And so you don't have to feel compelled to reply to
them. They are also not criticisms. So you won't have an urgency
of replying to them.
But just for our own work, I wanted to note two things that
struck me while you were talking. One was a place where you were
talking about that New York Times article that you had included in the
briefing book. And you had the sentence about "These feelings
mark the transfer of causal efficacy from will to pill."
That clearly relates to our discussions about dignity. I
mean, that dignity is not just a theoretical discussion, in fact. If
you're right, then there's something wrong with what Patricia
Churchland was up to this morning, not in her presentation, which had
nothing to do with it, actually, but in the paper that she had
And so there are connections, actually, between what you
are talking about and those larger theoretical questions that we're
taking up in a sort of different area of our work.
The other thing, as I found myself listening to you, I was
thinking, "Yes, but we can't correct the profession of
psychiatry. We can't." And I started feeling sorry for
teachers who would be asked to try to accomplish this. I mean,
it's not a job I would want to undertake. And I'm not sure
that we can correct that either.
Another phrase you had with respect to just the medications
that these children are receiving, you spoke of a vast, untracked
experiment in clinical neuropharmacology. Bioethics, one of the things
it deals with is research, experimentation, and the ethics that ought
to govern it.
And if there's really a vast, untracked experiment
going on, then that is a legitimate bioethical concern that it seems to
me if we're thinking about sort of where does this big project that
we're sort of rummaging around in come to focus in various ways is
one possible place where it comes to focus.
CHAIRMAN PELLEGRINO: Yes?
DR. SCHAUB: I know that is late. I've got one very
quick question. How much would sex-specific education help with this?
In other words, we may not be able to move our educational system
towards completely individualized education, but if there are some real
differences in the way boys learn as compared to the way girls learn,
would that help?
DR. BROCK EIDE: Yes. What you basically have with the two
populations of boys and girls, I mean, within each, you're going to
have a range of learning style. So you will have some boys that are
predominantly auditory learners. But they will be a much smaller group
than you will see among the girls. So you have different populations
that differ a lot from each other but are more homogenous within the
So each group has a splay, but it's a smaller splay
than the total population when you combine them together. So it would
be a big step in the right direction all the way throughout the
educational scale but especially during the early years.
CHAIRMAN PELLEGRINO: Any other questions?
PROF. GEORGE: Just to be clear, it would be single sex
education? sex-specific education is the it that would be —
DR. BROCK EIDE: That's right.
PROF. GEORGE: — good to have available all the way
DR. BROCK EIDE: That's right. That's right.
DR. FERNETTE EIDE: For options.
CHAIRMAN PELLEGRINO: Other questions?
CHAIRMAN PELLEGRINO: Thank you very much.
DR. FERNETTE EIDE: Thank you.
(Whereupon, the foregoing matter was concluded
at 5:47 p.m.)