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Meeting Transcript
February 2, 2006


COUNCIL MEMBERS PRESENT

Edmund Pellegrino, M.D., Chairman
Georgetown University

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

Robert P. George, D.Phil., J.D.
Princeton University

Alfonso Gómez-Lobo, Dr. phil.
Georgetown University

William B. Hurlbut, M.D.
Stanford University

Leon R. Kass, M.D., Ph.D.,
American Enterprise Institute

Peter A. Lawler, Ph.D.
Berry College

Paul McHugh, M.D.
Johns Hopkins University School of Medicine


Gilbert C. Meilaender, Ph.D.
Valparaiso University

Janet D. Rowley, M.D., D.Sc.
The University of Chicago

Diana J. Schaub, Ph.D.
Loyola College

INDEX

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 Government Representative.

I also want to welcome Dan who was appointed recently to the directorship and he is my boss now, officially.

(Laughter.)

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.

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 now.

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 neuroembryology.

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 a population.

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 group.

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 common.

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 it.

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 forth children."

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 for help."

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 this period.

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 kept separate.

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 access.

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.

Dr. Meilaender.       

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 disposition.

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 out-group.

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 move forward.

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?

(Laughter.)

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 force.

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 of women.

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 choice.

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 that's fine.

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 exist. 

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.

Thank you.

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 with you.

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 human dignity.

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" in general.

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 the conceptus.

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 for it.

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 are.

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 here?

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 ordeal.

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 flourish.

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 movement forward.

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.

(Laughter.)

DR. CHURCHLAND: Nobody has ever accused me of that before.

(Laughter.)

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.

(Laughter.)

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 Treaty.

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.

(Laughter.)

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 empirical point. 

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, and currently. 

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 —

(Laughter.)

— 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 there is?

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 conditions, do.

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 testosterone.

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 dignity word. 

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. Rowley.

DR. MCHUGH:  Well, it was terrific, Pat, and you're still your old sassy self.

(Laughter.)

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.

(Laughter.)

I'm an Augustinian, but that's besides the point.

(Laughter.)

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 biologically.

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 don't know.

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 that sort.

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.

Dr. George?

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 take over. 

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 break loose. 

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 him.

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 (CONT'D)

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 30 seconds.

(Laughter.)

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 dignity."

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 foundational notion.

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 would reject.

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 bear dignity.

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 control.

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 subjective notion.

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 bioethics.

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 valuer.

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 natural kind.

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 rationality. 

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.

(Applause.)

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 aristocratic understanding.

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 intrinsic dignity?

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 those questions.

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 notions.

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?

(Laughter.)

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.

(Laughter.)

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?

(Laughter.)

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 system.  

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 presentation.

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.

(Laughter.)

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 excellence two.

(Laughter.)

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 absolutes.

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 apple. 

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 it differently.

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 there.

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 just try.

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 question.

(Laughter.)

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 earth.

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 whole itself? 

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 that.

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 value.

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 the cosmos.

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.

(Laughter.)

DR. SULMASY:  Several of them.

(Laughter.)

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 Albert Einstein?

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 matter.

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, true.

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 control it.

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 the like.

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,

(Laughter.)

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 other patients.

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 discussion.

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 CHILDREN

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 children's ethics.

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 dimensions.

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 volunteer.

(Laughter.)

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 our time.

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 with.

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 human virtues.

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 task.

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.

Dr. Dresser?

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.

Other?  Gil?

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.

(Laughter.)

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 — Robby?

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 well.

Paul?

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, listen," —

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 "Babylon Revisited."

"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 in Paris.

"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 lot more.

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.

(Laughter.)

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 remember that.

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 it."

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 cocaine.

(Laughter.)

CHAIRMAN PELLEGRINO:  I was going to say you shouldn't either.

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 wrong.

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 pressing questions?

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."

(Laughter.)

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 games?"

"Oh, no, no, no.  They can play that for hours and hours."

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?

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 are awful.

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 says.

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 things.

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 a curb.

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 athletics.

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 are realistic.

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 real world.

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.

Gil?

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 questions.

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 dignity.

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 questions.

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 operation.

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 that.

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 a comment.

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 thing.

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.

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 philosophical issues.

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 concerned."

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 those things.

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 country today.

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 problem.

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 three.

We have to become specific.  I quite agree.  And, as a physician, I tend to look at some practical things, too, from time to time.

Yes, Gil?

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 review.

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 time.

(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 talking about.

Dr. Greenspan?

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 bio-psychosocial context?

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 society.

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 environments.

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 D."

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 way.

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 intent was.

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 to 12.

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 these milestones.

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 complex world.

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 world.

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 experience.

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 of sources.

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 behavior.

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 foundation-building approach.

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.

Thank you.

(Applause.)

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 bio-psychobehavioral approach.

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 functioning.

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 implement.

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 complexity.

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, in part.

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 be activated.

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 structure.

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 problems?

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 child development.

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 way.

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 it.

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 approaches.

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 at symptoms.

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.

(Applause.)

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 right ahead.

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 you.

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 about.

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 behavioral criteria.

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 dysfunction.

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 school.

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 from effects.

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 routine.

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 process itself.

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 and attention.

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 teaching style.

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 stupid.

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 child's attention.

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 ADHD, will.

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 system.

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 specialist.

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 for treatment.

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 behavioral pediatricians.

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 referring to.

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 moral capacity.

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 for others.

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 in IQ.

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 learning.

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 neuroplasticity.

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 ways.

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 attention problems.

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 children.

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 arbitrary frameworks.

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.

(Applause.)

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 perspective.

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 in education.

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 digits forward.

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 looks hopeless."

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 congenitally.

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 realize.

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 presented.

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 group.

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 through?

DR. BROCK EIDE:  That's right.  That's right.

DR. FERNETTE EIDE:  For options.

CHAIRMAN PELLEGRINO:  Other questions?

(No response.)

CHAIRMAN PELLEGRINO:  Thank you very much.

(Applause.)

DR. FERNETTE EIDE:  Thank you.

(Whereupon, the foregoing matter was concluded at 5:47 p.m.)


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