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Meeting Transcript
January 15, 2004


Wyndham Hotel
1400 M Street, NW
Washington, D.C. 20005

COUNCIL MEMBERS PRESENT

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

Rebecca S. Dresser, J.D.
Washington University School of Law

Daniel W. Foster, M.D.
University of Texas, Southwestern Medical School

Francis Fukuyama, Ph.D.
Johns Hopkins University

Michael S. Gazzaniga, Ph.D.
Dartmouth College

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

Mary Ann Glendon, J.D., L.L.M
Harvard University


Alfonso Gómez-Lobo, Dr. phil.
Georgetown University

William B. Hurlbut, M.D.
Stanford University

Charles Krauthammer, M.D.
Syndicated Columnist

William F. May, Ph.D.
Southern Methodist University

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

Michael J. Sandel, D.Phil.
Harvard University


INDEX


WELCOME AND ANNNOUNCEMENTS

CHAIRMAN KASS:  Happy New Year everybody.  Welcome to this, the 15th meeting of the President's Council on Bioethics.  Welcome to Council Members, and to staff, and to members of the public.

I would like to acknowledge the presence of Dean Clancy, our Executive Director, the Designated Federal Officer, in whose presence this is a legal meeting.

And there is one other announcement, and an elevation in the staff, of Yuval Levin to the Deputy Executive Director's position, and I want to congratulate Yuval.

SESSION 1: STEM CELLS: COUNCIL'S REPORT TO THE PRESIDENT

CHAIRMAN KASS:  The first session this morning is devoted to officially releasing the latest council document, our third report, a report, entitled, "Monitoring Stem Cell Research," which council members should find at their places.

This report to the President is offered as an update on the state of human stem cell research, reviewing both the science of stem cells, and the public and scholarly debates that have arisen around it over the past several years.

We as a Council have been looking at these issues and thinking about this subject from our very beginning.  The President decided to create this Council in the course of his review and decision regarding government funding of embryonic stem cell research, and one of the things that he asked us to do when he created the Council was precisely to keep an eye on this field for him and for the American public.  And that is what we have done.

We have devoted a large number of Council sessions to this subject, at least 14 sessions by my count, beginning at our third meeting in April of 2002.  We have commissioned review articles and heard presentations from prominent researchers in all the various areas of human stem cell research. 

We have heard from ethicists who have thought about these issues for years.  We have heard from experts in the legal and legislative side of these questions, from people working on the stem cell research in the private sector, and in publicly funded studies.

We have heard from patient advocates, and we have heard from the Director of the National Institutes of Health, and the Commissioner of the Food and Drug Administration, and many others who gave us their views and who reported on the facts in oral and written presentations to the Council.

The staff has conducted vast reviews of the literature, and special thanks to Lee Zwanziger for the review of the ethics literature, and to Dick Roblin for monitoring and keeping track of the scientific literature. 

The Council's report draws on all of that, and on a great deal of additional discussion and work by Council members and by the Council staff.  It synthesizes what we have learned through monitoring in what is essentially an update on the present state of things more than two years after the adoption of the administration's current policy on federal funding of embryonic stem cell research.

The report has gone through multiple drafts, received extensive and painstaking comments from members, reviewed equally painstakingly by the staff, and the scientific chapter, Chapter 4, has been additionally reviewed for accuracy and fairness by some prominent stem cell researchers not connected with the Council. 

We are grateful to all those who have helped us in the various phases of our work.  To understand the document it is very important to understand what I mean when I call it an update. 

Because the field and the current policy are so young, this report can be no more than an update.  It summarizes some of the more interesting and significant developments since August 2001, both in the basic science and medical applications of stem cell research, and in the related ethical, legal, and policy discussions.

But it does not attempt to be a definitive or comprehensive, or ultimate study of the whole topic.  It contains no proposed guidelines or regulations.  Indeed, it contains no specific recommendations for public policy.

That was not our task or our purpose here.  Rather, it seeks to shed light on where we are now ethically, legally, scientifically, and medically, in order that the President, the Congress, and the nation, may be better informed as we all consider where we should go in the future.

To be sure, Members of the Council do have particular views regarding the best public policy on this subject, and there are differences of opinion on this subject among us. 

But in this report, we seek not to settle that debate, but to improve it.  The debates about this subject in the past two years have often suffered from a great deal of confusion, frankly, on all sides.

By offering the best available information on both the science and the ethical arguments, gathered together in once place and available for any interested party to consult, we hope that this monitoring document will be able to establish a clearer picture of the facts and the contending opinions so as to act as the foundation for a better informed continuing discussion of this important policy topic.

Our aim here, therefore, is in a sense limited, but it is still a very large, extremely important one.  With that as a general preface, let me give you a short guided tour of the document, beginning with its more specific goals.

The report has, I would say, four basic goals.  First, to explain and clarify the existing federal policy regarding taxpayer funding of stem cell research and its implementation.

Second, to offer an overview of the public debates surrounding stem cell research in the past two years.  Third, to provide an update on developments in all areas of human stem cell science in the past two years.

And finally, a kind of over- arching goal that defines for us the entire project, to convey the moral and social importance of the issue at hand, and to demonstrate how people of different backgrounds, ethical beliefs, and policy preferences, can reason together about it in a constructive and publicly responsible way.

And those of you who have copies may want to follow the table of contents.  I am just going to run through and highlight a few of the important points.  The report opens with a brief introductory chapter, in which we take up some very important questions of context, terminology and purpose.

Then in the second chapter, the report addresses — first addresses itself to the first of the aims that I have described, namely to describe as clearly as possible the present federal funding policy, its character, and its implementation. 

The policy, I think it is fair to say, is founded in a desire to promote important biomedical research without using public funds to endorse, support, or create incentives for the future destruction of human embryos.

The report tries to describe this aim in the context of its history, of the history of federal funding of embryo related research, including the Dickey Amendment, and in the context of what we take to be the legal, ethical, and prudential foundations of the policy.

We also give some consideration to the unique and important questions that surround all federal funding decisions.  What does it mean for the government to support an activity with taxpayer money?

What sorts of considerations should go into a funding decision, and the Council suggests that a funding decision is always an ethical, as well as an economic one. 

Finally, in the second chapter, we try to lay out the basic facts regarding the implementation of the Administration's funding policy over the past two years, to explain how the NIH has put the policy into action, and where things stand in terms of available funding and available lines.

There has been a lot of confusion about this, and I think it is critical to put the facts out there as fully and plainly as possible.  The basic facts on that front are that there are 78 lines of human embryonic stem cells that have been found to be eligible, eligible for federal funding under the current policy.

That is, those lines were derived before the date of the President's speech.  But these lines are in different stages of characterization and development, so that only some of them have been developed to the point that they are actually available to researchers who want them today.

Others are still being developed, and, of course, it is impossible to know in advance how many of these will finally in fact prove to be usable, the important distinction between what is eligible and what is available.

And here we run into one of the difficulties of reporting on a field that is constantly changing.  The number of lines available to researchers has been growing over the past two years as more of the eligible lines have been developed and characterized. 

A year ago, about five lines were available.  This fall when we were completing this report, the number had risen to 12 lines, and so 12 is the number listed in this document.

But since that time, at the end of December, the NIH reports that three additional lines have become available, and so the number is now 15 lines rather than 12. 

We note very clearly in the report that this number will continue to change and so this very recent increase in the number of actually available lines only underlines that fact, but it does not change any of the major points made in the document, and in the final version of this report, we will update those facts, as well.

The funding policy, though it limits the targets of funding to the eligible lines, does not directly delimit or restrict the amount of money, or other resources that the NIH may invest in human embryonic stem cell research.

The amount invested is a decision left to the NIH and the Congressional appropriations process is largely a function of the number of qualified applicants for funding, and of the NIH's own priorities and funding decisions.

In Fiscal Year 2002, the NIH devoted approximately $10.7 million to human embryonic stem cell research, and based on an estimate that we received in September of 2003, it will have spent approximately 17 million in Fiscal Year 2003.

Still, however, only roughly ten percent of the amount spent on adult stem cell research.  This amount is expected, as the field and the number of grant applications grow.

Having laid out the character and state of implementation of the present funding policy, the report then turns to a review of the public debate, which, as you all know, has been quite active and quite contentious over the past two years. 

A great deal has been written and said, and there have been Congressional hearings on these subjects, many books and articles published, many different sorts of arguments put forward on all sides, and we have been monitoring these activities for over two years.

The third chapter of this document, which is the longest chapter, tries to offer an overview of these debates.  It makes no claim to be absolutely comprehensive, of course. That would be more than any document like this could hope to do.

But I do think that it describes and organizes all the major strands of the public debate, and that it presents these in a way that might allow people to get a sense of what the issues are, and what the arguments are, and what there is to think through.

We have organized the discussion in relation to the current policy and its moral and prudential underpinnings so that the reader may see the way in which the ethical debate can have practical traction regarding policy.

Subtopics include challenges to the moral aims of the current policy, challenges to some of the internal features of the current policy, efforts to try to cut the Gordian Knot that is the moral standing of human embryos, and other social and public issues less frequently discussed, but perhaps no less important.

As we conclude our overview of the ethical debates, strong and powerful — and I quote from the report — strong and powerfully argued views have been presented on various sides of each of these questions.

For now, neither side to the debate seems close to fully persuading the other of the truth it thinks it sees, but the rich and growing ethical debates do suggest the possibility of progress toward greater understanding of the issues, and toward more important and informed public decision-making as all parties to the deliberation appreciate better just what is at stake, not only for them or their opponents, but indeed for all of us.

In presenting these arguments, we have tried to present them, the arguments and the counter- arguments, faithfully and accurately, so that each reader can judge them for himself or herself.

I should add, by the way, that some of the points and some of the arguments described actually originated in the discussions of this Council, and, of course, those are clearly cited in the text, just like all of our other sources.

Finally, and, of course, absolutely crucial to any discussion of human stem cell research, is a rigorously informed sense of just where the science now stands, both in basic research and in therapeutic efforts using animal models.

We have sought to offer readers of this report both an explanation of what the science of stem cells involves, and an update on recent developments in the current state of human stem cell research, understanding, of course, that the field is always changing.

At the heart of this effort are seven commissioned review articles written by leading scientists covering the published literature as of last summer on embryonic stem cells, and embryonic germ cells, adult stem cells, multipotent adult progenitor cells, mesenchymal stem cells, and stem cells from cloned embryos. 

And a seventh paper on the problem of immunological rejection, one of the obstacles to eventual successful tissue transplantation.  These papers appear unedited in their entirety, in the appendices H through N in the report.

As an adjunct to these Commission review articles, the fourth and final chapter in the body of the report proper seeks to enable especially non- scientific readers to appreciate the reasons for the excitement over stem cell research, the complexities of working with stem cells, some early intriguing research and therapeutic findings, and the difficult road that must yet be traveled before we can reap therapeutic and other benefits from this potentially highly fertile field of research.

Along with the scientific appendices and several other Commission papers on ethics and policy that are offered as appendices, the report also includes what we have called an embryo primer.

This is the first appendix of the document, and it offers basic facts about human embryology that we think any reader should know before coming to judgment about the issues that surround human embryonic stem cell research.

The scientific facts don't simply settle the moral or policy questions by themselves, but they are, of course, quite crucial to any understanding and determination on that subject.

In short then, the report aims to describe the present policy to review the social and ethical debates, and to offer an update on scientific developments.

And these three aims, as I have said, are overached by this desire to convey to the reader the tremendous importance of the issues at hand, and to show that we, as a society, can think about them together.

I think the Council's work in putting the document together demonstrates that, too.  Throughout the Council's deliberations, and in this Monitoring Report, mostly successfully, to acknowledge the strengths and importance of opinions and concerns held by people with whom we personally might disagree.

We have aspired to be careful and fair in our approach, precise in our language, accurate in presenting data in arguments, and thoughtful in laying out the various issues that remain before us.

These have been our aims in this document, and I would like to think that the report achieves its aims, though that is for the readers to judge.  We do hope that this will help to inform the very important and complicated ongoing public debate.

I would like, in closing, simply to offer special thanks to members of the staff who are especially responsible for this report.  Everyone had a hand in it, but Lee Zwanziger, Dick Roblin, and Yuval Levin.

That is my synoptic view of the report.  The procedure is that there are a few members who have asked to make brief comments on the report, and then we will open the floor to questions from the press.

Two of our members are still in transit — actually probably Charles as well.  Elizabeth Blackburn, who cannot be with us today, has sent in a comment which she has asked me to read, and let me begin with that, while others who have asked to speak will come next.

This is from Elizabeth, and I quote:  From the scientific published literature and peer review journals on stem cells, a major message that can be distilled is the vast difference that currently exists between embryonic and adult stem cells as sources of material for research and clinical purposes. 

Briefly stated, human stem cells have been isolated from a variety of embryonic, fetal, and adult tissue sources.  However, enormous differences exist in purity, properties, data reproducibility, and understanding of cells from these different sources.  Paragraph.

First, embryonic stem cells have been extensively and rigorously demonstrated in animal models to have great utility for scientific studies, and this work has also shown that human embryonic stem cells, together with fetal stem cells, show the greatest promise for clinical applications.

As well as therapeutic uses, important additional potential applications include studies of stem cells bearing complex genotypes susceptible to poorly understood common human diseases, and testing and screening throughout efficacy.  Paragraph.

Second, the only well- characterized adult stem cells that exist to date are hemopoietic stem cells.  These are the only ones that have been well characterized in multiple laboratories and are reliably understood. 

Currently, major difficulties exist with other types of adult stem cells reported to date.  Research on some of the reported adult stem cell preparations may conceivably in the future demonstrate that they, too, like hematopoietic stem cells, can also be, "single cell cloned," expanded considerably by growth in vitro with retention of normal chromosome structure and number, and preserved by freezing and storage at low temperatures.

But it should be strongly cautioned that this is not been done, and even if possible, it will be technically very demanding.  Paragraph.

Furthermore, in the case of MAPCs, and that is the multipotent adult progenitor cells, the work of Catherine Verfaillie, and furthermore in the case of MAPCs, for example, the reported isolation and properties of MAPCs must be reproduced in additional laboratories for any reliable interpretation of the results reported with these cells. 

After considerable effort this has not been achieved to date.  Thus, it remains extremely difficult to interpret these results rigorously.  Therefore, it is important to note that in light of this failure to reproduce the reported results as of now, the significance of the reported isolation and properties of human MAPCs is still left unclear, as is, therefore, their potential as a source of stem cells for clinical purposes.

Hence, a strong overall caution is that many of the reports of the properties of cells differentiated from adult stem cell preparations, other than hematopoietic stem cells, are, to date, preliminary and still very incomplete.  Paragraph.

If and when the results to date with any isolated and characterized adult stem cells are validated, it will then be very important to compare their properties, and those of any more differentiated cells that can be derived from them with other stem cells sources. 

These sources include adult stem cells, such as the well characterized hematopoietic stem cells, and the human embryonic stem cell preparations that have already been more extensively characterized.

Two major considerations argue strongly for non- commercial federal peer- reviewed funding to be made available for this work.  The first is the sustained effort this work will require, the second is the importance of reliable and unbiased design of experiments, and of open public availability of the complete findings arising from the work.

I have been told that, I think, Alfonso Gomez- Lobo has a comment, and I believe Robby George.  Alfonso, please.

DR. GÓMEZ-LOBO:  Thank you.  We have in our hands a valuable document that has been carefully crafted by our admirable staff under the guidance of Dr.Leon Kass.

The document contains illuminating presentations by the experts we invited to instruct us on different topics.  And it also incorporates a significant number of contributions from members of the Council who spent long hours sifting through the successive drafts.  It is, on all accounts, a significant achievement. 

What I would like to do in this brief statement is to express my own exegetical hopes, that is, my personal hopes with regard to the way that the report will be read and understood. 

My first hope is that the abundance of scientific information and funding policy questions would not obscure the fact that this is a report issued not by a scientific panel, but by a council on bioethics, a body primarily expected to address ethical concerns. 

It is my hope that readers of the report will realize that by the end of the day there is but one central ethical concern in embryonic stem cell research, namely, that at the present time human embryonic stem cells can only be obtained by deliberate destruction of live human embryos. 

It is my hope that readers will also realize that research on adult, or non- embryonic stem cells, raises no equivalent ethical concerns because no destruction of human organisms is required.

In spite of the fact that opinions on how human embryos should be treated are deeply divided, my hope is that the report will not be read as espousing skepticism on whether we can reach a rational solution to the question of when the life of a human being begins, and when respect for that life ought to begin.

I hope that our further scientific work in animal models on the embryonic stage, especially on twinning, will allow us to make better inferences on those topics, and I hope that further conceptual work on the notion of  "special respect" and "intermediate moral status" will show whether or not those concepts are adequate to express what we owe to humans who find themselves at a stage we all went through early on.

My own view is that the notion of special respect allows us to discriminate among embryos on the basis of the circumstances in which they have been placed, and fails to raise a protective barrier in front of hundreds of human embryos that are genetically no different from those that will not be used for research, and will be allowed to further develop. 

Finally, I hope that reflection on the fact that every human being alive today went through the embryonic stage would lead us to understand that the fruits of embryonic stem cell research will come at the disturbing price of humanity turning against itself.  Thank you.

CHAIRMAN KASS:  Robby George.

PROF. GEORGE:  Thank you, Leon.  Today's report does not seek to settle the question of the justice of human embryo destruction and the cause of biomedical research. 

On that question, it sets forth the reasons why some of us oppose the taking of human life even in the embryonic stage, and others believe it to be justified where it is done with the realistic hope of helping people who are afflicted with serious illnesses and disabilities.

Nor does our report offer an evaluative judgment of the policy put into place by the President of the United States on August 9th, 2001, restricting federal funding of research involving the destruction of embryonic human life. 

On this question, too, we are divided as a nation and as a Council.  The report makes a contribution, however, by clarifying the grounds and meaning of the policy, and by providing reliable information as to its implementation and impact. 

As for the grounds of the policy, and its coherence, or possible lack of coherence with this or that view of the moral standing of the human embryo, and the moral permissibility of embryo destruction and research, the report makes clear that there are, on the Council, differences of opinion.

Again, the report does not seek to resolve these differences, and so it should be understood that the purpose of the report is descriptive rather than prescriptive.

It sets forth facts and it does not take positions on matters on which the council is fundamentally divided.  Those of us who believe that a policy of funding research involving the destruction of human embryos would be unjust share with our colleagues a desire for stem cell science to go forward unimpeded where research can be conducted without taking nascent human life.

We are heartened by the clinical successes of adult stem cell based therapies.  Such therapies are already in very encouraging clinical trials in humans for Parkinson's disease, multiple sclerosis, immune- deficiencies, sickle- cell anemia, and other afflictions.

Certain adult stem cell based therapies have already enabled some patients with Type- I diabetes to throw away their insulin needles.  While taking into account Dr. Blackburn's caution about the so far preliminary and incomplete status of research on multipotent adult progenitor cells, MAPCs. 

We believe that promising and ethically unimpeachable research of this kind should be encouraged and generously funded.  We do not wish the controversy over embryonic research to mislead the public into supposing that there is something ethically suspect about stem cell research in itself.  There is not. 

There are forms of important stem cell research that Americans can unanimously and enthusiastically support, despite our differences on other forms. 

It is important not to hype adult stem cell research, but it is equally important not to obscure its achievements and very considerable promise.  By the same token, it is important not to hype the benefits or promise of embryonic research.

I do not believe that the evidence supports a claim that embryonic stem cells show the greatest promise for therapeutic uses.  The difficulty in controlling them and their tendency to tumor formation makes them too dangerous for clinical trials at this time.

Very recent studies suggest that embryonic cell cultures may tend to accumulate extra chromosomes over time, the very chromosomes associated with the formation of cancerous tumors.

These problems may or may not eventually be solved, but plainly they need to be soberly taken into account in any presentation of the matter.  At the same time, no one would wish to prevent or impede research if stem cells of the type currently derived by destroying embryonic human life could be derived without resort to embryo destruction. 

The report that we issue today for the first time follows up a possibility raised by our colleague, William Hurlbut, in his personal statement attached to our earlier report on human cloning.

Today's report suggests the possibility, the possibility, of deriving cells from entities whose initial properties in certain ways resemble those of living human embryos, but whose direction of growth and trajectory of development due to epigenetic differences are quite distinct. 

Such entities, roughly analogous to hydatidiform moles or other disorder growths sometimes appearing in nature would not qualify as whole living members of the human species, or the species, homo sapiens.

On no one's account would they be considered embryonic human beings.  If in fact these entities were capable of yielding embryonic type stem cells, these stem cells could be harvested without raising the ethical issue of embryo destruction. 

Whether entities thus envisaged can be produced is a matter of fact that I think should be explored.  Whether their production would raise ethical questions that perhaps Dr. Hurlbut and I have not considered, others have to say.

But given the ethical impasse in the country and on the council on the issue of embryo research, I am glad that our report today elevates the profile of Dr. Hurlbut's proposal.

I commend him for seeking to address a vexing and divisive issue with a creative solution that would honor the concerns of reasonable people of good will across the spectrum of opinions.  Thank you.

CHAIRMAN KASS:  That was all I knew of people who had asked for comment in advance.  If I am correct on that, then I don't know that we have members of the press here that would like to ask comments or ask questions about the report.

We have a microphone which is over to the side.  Could we have that moved more centrally.  Are there any questions?  Please, for the transcript, would you mind stating your name, and if there is an identification that goes with it, it would be helpful.

MR. OTTO:  Yes, I am Alexander Otto, and I write for the Bureau of National Affairs Medical Research, Law, and Policy Report.  Recently, New Jersey just passed a law explicitly making legal research on embryonic stem cell derived from human cloning. 

It follows California's similar action of a few years ago, and, of course, bills are pending in other states to do the same thing.  How does this state action affect the debate on the federal level?

It is a very general question, but I would like to see it addressed by the panel, if possible.  Thank you.

CHAIRMAN KASS:  This is not a question about our report, right?

MR. OTTO:  Right.  It is not.  It is more a general question, if you could address it.

CHAIRMAN KASS:  Well, I am sort of two minds, and one could say that this would be a lengthy off- the- subject topic that we probably shouldn't go into.  On the other hand, we don't often get questions from the floor, and maybe a sentence or two wouldn't be out of order, and if I get it wrong, my colleagues will correct me. 

There is no law in the United States forbidding stem cell research or research on human cloning at the present time.  Those state laws are in a certain way gratuitous. 

They are simply declaring not so much that certain kinds of things are legal there.  Those things were legal there before.  They have given sort of the state blessings and announce that this state is in favor of those things in an affirmative way. 

Not unless and until there would be a national policy that would declare some of those things illegal would there be any kind of conflict between those state laws and what transpires at the federal level.

The federal question, at the moment, here is a question of federal funding and the funding policy.  There is no ban on any kind of embryonic stem cell research at the federal level.

So, I mean, there are different dispositions at work in these States, and in the Congressional debate, but I don't think — I think I am right in saying that there is absolutely no conflict at all.  My learned legal counsel.

PROF. GEORGE:  I just would enter one caveat about that.  I don't think it is quite right to say that there is no law in the United States restricting those kinds of research.  I believe that there are some state laws that go in the opposite direction —

CHAIRMAN KASS:  No, I understand, but there is no federal law.  Excuse me.  The states are free to be more restrictive, but —

PROF. FOSTER:  Well, let me just make a brief comment, and I can only talk from the state of Texas where I am.  The driving force for the states has to do with economics. 

Everybody in the world wants to have biotechnology in their state, and the companies, the economic impact of not saying that a state will support this type of activity is extremely powerful, even in a conservative state like Texas.

In fact, I was at a two-day conference just this last week about this issue after the new state decision.  So I think that the driving force there is independent of what we do here, but it powerfully economic.

I mean, the big states are going to be terrifically hurt if their idea has to do with — you know, no company will come, and no graduate students, or a few graduate students will come to the universities and so forth if you don't do it.

That is the concern, and I think it is the first thing.  The other thing that I mentioned that is not in the report is that at one point there have been five appellate court decisions about the nature of stored embryos.

So, there are legal decisions, mostly in divorce cases, in which the courts have — and including very high courts, and I guess maybe the highest court in New York, and in Tennessee, that have basically decided that the embryo is deserving of special respect, I understand, Alfonso, that that term is very vague.

But have basically decided in terms of contracts and so forth that the stored embryos are to be dealt with like other property in a divorce if I understand that.  That is what legal people tell me the decision is.

So, all I am trying to say is that there are a lot of other things going on that are outside the ethical issues that we are talking about here. 

CHAIRMAN KASS:  Thank you very much.  Cynthia Cohen, please.

MS. COHEN:  I am Cynthia Cohen, and I work at the Kennedy Institute of Ethics at Georgetown.  I am a philosopher and a lawyer by training.  I was interested in the fact that the Council is not coming out with any new guidelines and regulations. 

The second charge that you have on page one here is not only to monitor stem cell research, but to recommend appropriate guidelines and regulations.  And you mentioned that you have not had that much time, that this is still a growing field, that there is a difference of opinion on the Council about some matters. 

But, I wondered whether, for instance why there is no recommendation for an oversight body as there is in Canada.  I have just been appointed to the Canadian Ethics Oversight Committee.

CHAIRMAN KASS:  Good.

MS. COHEN:  And they are concerned about doing a strictly ethical review of their stem cell research.  In the United States the NIH is in charge of review, and it is primarily a scientific review. 

There was a mention of some of the economic concerns that are arising.  As stem cell research spreads, patenting issues, questions about what is going on in the private sector, I think you would have recommendations about that. 

So I am just puzzled, and I hope that you can help me to explain this to readers of the journal when I write this meeting up.  Thank you.

CHAIRMAN KASS:  Well, thank you.  I guess there is several parts of an answer to that question.  I think the primary answer is that this field is young.  The current policy is very young.  The implementation of that policy moves slowly, although the NIH has made it very clear, and the evidence is considerable, that they have strained every nerve to get this thing up and running as fast as possible.

And it seemed to us premature to jump in and second guess the current arrangements before one has given them even a couple of years time to work.  Stem cells, human stem cells, isolation, embryonic stem cells, the first isolation reported in 1998.

The announcement of the new funding policy in August of 2001.  The lines just becoming available, and the funding sources just increasing.  The research only beginning to be reported. 

It seemed premature to, at this time, to do more than simply monitor and report what has been going on.  Down the road, we might very well revisit this after there has been more experience and more opportunity to see whether things are working, and what else needs to be done.  That would be part of the answer.

The other part of the answer is that the Council is interested in the larger question of oversight, monitoring and regulation of biotechnologies, and we have another project. 

And, in fact, the subject of the second session this morning, biotechnology and public policy, an investigation of those technologies that touch the beginnings of human life.

And I don't want to preempt the discussion of that topic, but there have been serious considerations about the possible need for new institutional mechanisms to oversee these matters, and to monitor them, and then perhaps to regulate them. 

I think it is fair to say that the Council on that subject is not yet in the position to make institutional recommendations so that we will be producing some kind of diagnostic document, with some interim recommendations.

But the larger subject that you ask about is pretty much on our minds, but we wouldn't think of isolating it just to the question of stem cells.  I think that would be kind of a two- part answer.

PROF. MEILAENDER:  Leon, could I just make one comment, in response to that?

CHAIRMAN KASS:  Yes, Gil.

PROF. MEILAENDER:  It's not as if we have made no recommendations either.  I mean, you have to remember that the first thing that we produced was a document on human cloning and human dignity, which though somewhat different, certainly is related to this general topic, and embroiled thus in aspects of this topic.

And we had recommendations, certain kinds of policy recommendations there, but majority and minority views.  So, you have to read this in conjunction with our other work, I think.

CHAIRMAN KASS:  Yes, and there, however, the question was that there was a particular legislative debate into which we were pitted.  And here — and there was — and here we enter with a request to monitor the goings on under the current policy as announced.

So that the situation is — I mean, I think Gil is right, but the situations are not exactly the same.  Please.

MS. FRIEDEN:  I am Joyce Frieden, and I write for Ob- Gyn News.  You mentioned in your introduction that I think that 78 stem cell lines, I think, was the number that were available, and I just wanted —

CHAIRMAN KASS:  No, that were eligible.

MS. FRIEDEN:  That were eligible for funding.  I just want to make sure that is the upper limit, and if you have any idea if any of those 15 that you said were currently available, and what you think the eventual number is.

CHAIRMAN KASS:  There is no way to know how many of these — let me repeat.  Eligibility is defined by the announcement of — when the President made his announcement that there would be funding for lines already in existence as of the date of the announcement.

And we have got some discussions and I don't want to rehearse the details of the policy, but to be eligible the embryonic stem cell line had already to have been derived and the destructive — the embryonic destructive act had already to have taken place.

Before — and let's say in the spring or the winter of the year 2001, the loose estimates were that maybe there were 20 such lines existing world- wide, and while the President was deliberating about that policy, people at the NIH were scurrying about.

And if I am not mistaken, when the policy was announced, it was something like they thought there were 64 such eligible lines.  Further research revealed that there were now, I think — that there are now 78.

And who knows whether there is somebody who is harboring something someplace else that is eligible, but that is not the important question.  The important question, really, is how many of these eligible lines becomes sufficiently well developed, sufficiently well characterized, that the material transfer agreements are reached so that these become available to scientists for use.

The NIH monitors this carefully and it keeps a register of all of the eligible lines, and which ones then become available, and there are now, as of the end December, 15 such lines listed by the NIH.  The additional three lines coming one from Wisconsin, and two from Technion University in Israel.

But the NIH has a website for this, and they keep this information current.

MS. FRIEDEN:  Thank you. 

CHAIRMAN KASS:  And by the way, no one knows — it would just be fruitless to speculate in advance how many of the remaining 63 lines will become available.  Further comments, questions?

(No response.)

CHAIRMAN KASS:  Let's take an earlier break and convene at, say, five after 10:00 to get started on the second session, rather than just sit.  Thank you very much.

         (Whereupon, at 9:44 a.m., the meeting was recessed and resumed at 10:22 a.m.)

SESSION 2: BIOTECHNOLOGY AND PUBLIC POLICY

CHAIRMAN KASS:  Thank you.  Welcome to Janet Rowley.  We are expecting Mike Gazzaniga and Charles Krauthammer, who are both in transit.  This is the second session on biotechnology and public policy, and is devoted to a discussion of the staff working paper, entitled, "U.S. Public Policy and the Biotechnologies That Touch the Beginnings of Human Life:  Draft Recommendations, Revised."

I think council members don't need much by way of rehearsal of what this project is, or what we are doing, and why.  Suffice it to say that we have for some time, really from the very first meeting, been interested in the monitoring and regulatory institutions that concern the uses of biotechnology in general, and that we focus that interest on the technologies touching the beginnings of human life where already established technologies of assisted reproduction now become joined with possible new developments growing out of genomic knowledge, and the availability of embryos for research.

We are on our way toward a report on this subject, the bulk of which will be a diagnostic section of some length reviewing where things now stand. 

A brief section already has been discussed and basically approved on policy options, both general and particular, and a last section which we discussed both in September and in October on interim recommendations, recommendations for the time being while the Council and the nation continue to deliberate about what if anything needs to be done to improve the way in which we now oversee, and monitor, and regulate these activities.

We in September had a discussion of the first draft of these recommendations, and it was a very spirited and somewhat woolly conversation.  We returned in October, where we made I think considerable progress amongst ourselves.

A number of things were clarified, and a number of issues in which it looked like we could find no agreement, and we managed to produce a kind of agreement amongst us. 

And the document has been changed extensively to reflect those conversations amongst ourselves with a number of things being removed that were contentious, and other things being refined.

I will say, and I think that I would like to put in the record that this latest draft also reflects changes that we have made in response to comments by various stakeholders, including patient groups and professional societies.

We have met with the — we already met the last time with the President and the Executive Director of the American Society for Reproductive Medicine.  We have since met with representatives from RESOLVE, and from the American Infertility Association.

And I want to go through a few of the changes that have been made, because I would also like to say that to some extent the concerns of some of these groups have originated from at least a partial misunderstanding both as to the substance of our document, and our intentions.

Nevertheless, they have offered some very helpful comments, calling our attention to ambiguities or to problems that we might be causing of which we were not aware.

And we have responded in great detail to some of their concerns, and so that Council members don't have to sit with the last draft and the current draft, let me just highlight a few of these concerns, and put on the record some of the things that we have changed.

First of all, there has been a concern that some of the monitoring activities that we were calling for would produce government intrusion and stigmatization.  That we were calling for measures that would involve undue intrusion of government into the domain of ART.

That we would lead infertile patients and their children to be stigmatized by being monitored and registered, and that there was a concern that the studies that we were calling for might imply mandatory participation and create a de facto registry of children born with ART, though that was not our intent.

We have modified the document to expressly state that participation in all federally- funded studies should be fully voluntary as we had all along intended.  We removed the recommendation that the ART children be tracked through the first year following their birth, thus avoiding the inadvertent creation of a mandatory government registry of such children.

We have modified the document to note that the vast majority of our recommendations requesting additional information calls in fact for the publication of data that is already being collected by the CDC under the Wyden Act, but not made public.

And we have eliminated from this document our recommendation relating to the tracking of in vitro embryos produced during ART.  There has been some concern about sowing alarm and confusion about some of the terms having to do with the way that the data is reported, and the reporting of costs.

And I won't bore you with the details, but we have put in suitable modifying language to address those concerns.  A major concern was that our recommendations might lead to restrictions on access to assisted reproductive technologies, and the reasons that were given included the following.

That the recommendations for increasing reporting and monitoring might give rise to increased costs, which would then be passed on to patients due to this requirement of increased oversight. 

That people sensed that there were certain restrictions that we were recommending on the use of embryos in clinical and research contexts; and third, that there were restrictions on certain practices that were integral to ART, such as gamete and embryo donations, surrogacy and the like.

Partly, this, I think, rested on misunderstanding, and partly there were important issues to be discussed, and the new draft makes it expressly clear that our recommendation to increase the CDC's funding is aimed precisely at shifting the costs of any new oversight activities to the government rather than to the patients.

The draft makes it very clear that we are not calling for in vitro embryos as such to be treated as patients or human subjects of research, and the language that led some people to think otherwise, such as "child to be," or "future child," has been replaced with "children later born."

The concern throughout is to make sure that we safeguard the health and well- being of the children who are born as a result of these procedures, and that was always the intent.

If the language was confusing, that has now been eliminated, and the new version makes it clear that we are not calling for any kind of ban on gamete or embryo donation, surrogacy, the reimbursement for reasonable expenses incurred in the course of such practices, et cetera, et cetera.

So I think that we are very glad that these concerns have been called to our attention, even in places where we think they rested on some partial misunderstanding, and I would like to think that the new version of the recommendations addresses the concerns of the stakeholders, as well as the concerns of the Council members.

The goal for today is I think simple.  We were very close I think to an agreement on most of the things that are here.  The recommendations in the interim recommendations are in three parts:  (1) Recommendations for federal studies, data collection, reporting and monitoring, regarding the uses and effects of these technologies; (2) recommendations for professional — for increased oversight by the professional societies and practitioners; and (3) recommendations for targeted legislative measures to defend the dignity of human procreation. Those are the three sections.  And my goal today, and I think we should be able to achieve it, is to try to reach the agreement on the gist of these provisions, leaving the line editing and refinements for later.

The rest of the document has been reedited, and will be sent to you shortly with a revised version of what we are talking about today, so that you will fairly soon be able to see the whole thing.

Given where we were on the stem cell report, and we didn't feel it was appropriate to burden you at this time with yet another hundred pages of document to be read carefully.  So that is coming next.

Any questions or comments on my opening remarks or on the procedure?  Frank, are you — you looked like you were on your way to say something?  No?

PROF. FUKUYAMA:  I have several things to say, but not now.

CHAIRMAN KASS:  Okay.  A note has been passed to me, and I might as well read it, that Jim Wilson, who is unable to be here, did send in a note saying that he endorses this document as written.  So that is at least in the record and on the discussion.

Shall we begin and go section by section, and not necessarily article by article, and see whether people have comments in the large, first of all, about the particular items recommended.  And Janet Rowley, please.

DR. ROWLEY:  I was not able to be here at the October meeting, but I did raise a point that I think is very important in the September meeting, that I don't believe is really addressed by the draft that we have currently. 

I think it is very important that we recognize that the problems that we are facing, that this draft is trying to correct if you will, are due to two factors. 

One is the Congressional prohibition against funding any research related to embryos.  So there is much of the text that relates to the fact that the procedures, and changes in procedures, are often not as carefully documented as they would be in other kind of medical procedures, and it is strictly a result of the lack of appropriate and adequate funding.

So all of the research that is done is paid for by fees from patients to various clinics.  So this should be part of the preamble; that Congress has really forced many of these problems because of its prohibition.

The second problem that arises is that from the standpoint of patients this procedure is not covered by health insurance.  As a consequence some of the other aspects that we are concerned about, such as multiple pregnancies, which do not happen in other countries where they have appropriate funding of patient care, do happen here because the clinics are — if you want to have a successful pregnancy, you put in multiple embryos, and this is recognized as a less than ideal medical procedure.

But it is strictly a result in this country of the way that we fund or do not fund health care for this particular medical problem.

CHAIRMAN KASS:  Any comment to that? 

PROF. MEILAENDER:  A question, just a question.

CHAIRMAN KASS:  Gil.

PROF. MEILAENDER:  Congress doesn't forbid all research on embryos does it?  It forbids research that involves destruction of embryos by federal funding of such research.  Am I not right about that?

We don't have any law forbidding research on embryos.  We have law prohibiting federal funding of research that destroys embryos.

CHAIRMAN KASS:  I think Janet's point would be something like this.  That attached to funding is very often the obligation for a certain kind of review, and that in the absence of a funding policy the government has lost — in Janet's view, has lost something of its leverage to actually regulate the funded activity.

And I don't think she was saying that this is outlawed, that the activity itself is outlawed.

DR. ROWLEY:  Well, it's in — I stand to be corrected by people who are more conversant with the specific details of the law.  But any sort of research trying to see whether Procedure A is more likely to give you viable embryos or viable embryos of higher quality, is inevitably going to lead to some of those embryos dying.

And that's because you are trying to see what you can do to improve it.  So I think that it is unrealistic to think that you can fund research on embryos that is focused on trying to improve conditions without as a necessary component of that being some research that would lead to the death of embryos.  And science is about comparing things.

CHAIRMAN KASS:  Robby.

PROF. GEORGE:  Janet, I just wanted to ask a question of clarification about your comment.  There were two parts to it.  The first had to do with what you take to be the implications of the prohibition on federal funding of embryo research or research that involves the destruction of embryos.

But as I understood your second comment, and this is what I wanted to be clear about, your second comment doesn't have to do with that?

DR. ROWLEY:  No.

PROF. GEORGE:  Your second comment is a more general criticism of the health care system in the United States, comparing it unfavorably, say, with the European systems.  That wouldn't have anything to do with whether embryo research is funded or not funded.

You are just saying that if we had a better and superior health care system overall that we would be relieved of such problems, which I would agree are very serious problems of, for example, multiple pregnancies, and the practice of implanting multiple embryos, with a view to having at least one survive and so forth. 

Just have I understood you correctly?  I am not here arguing with you.

DR. ROWLEY:  Right.  No, I think that is correct, and what I am saying is that these two factors play a central role in the problems that we are now trying to fix, but we are fixing it around the perimeter, and we are not dealing at all with some of the fundamental causes that lead to some of the concerns that members have.

And I think not to state this right up front is in my view a major deficiency of this particular document.

CHAIRMAN KASS:  Let me offer a comment in my own name, Janet.  I think — I take your point, and I wouldn't deny the relevance of both of those considerations to the situation that we have. 

But I think on the first point that when similar comments were raised in the past, there were responses to say that there are all kinds of things that the government can and does regulate that it doesn't fund.

And indeed the Wyden Act to require the reporting is an Act that Congress was able to enact, even though it could not get past funding for the embryo research itself.

So it makes it more difficult, I grant, but the Government regulates lots of activities that it doesn't fund, and therefore one cannot simply say that the reason that this is an unregulated area is solely due or primarily due to that.

It is a factor, but I wouldn't share your interpretation that that is the cause.  And second even on the question of health insurance, the profession has in fact tried very hard to set guidelines to reduce the number of embryos that are transferred.

There is professional self- regulation, and we are in effect calling on the profession to do more of that.  You don't need a national health insurance to practice responsible medicine, and it might help to remove certain kinds of financial disincentives to practice responsible medicine.

But again I wouldn't say that that is the sole explanation for what we have here.  I am very happy to include the points in the analysis, but I am not sure that I would include them as determinatative, (a), and (b) in the recommendations, you will recall that we are trying to look for those things that we can recommend, notwithstanding certain kinds of unbridgeable differences amongst us.

DR. ROWLEY:  But I would like to come back to this, because I think that we have agreed that the government requires things that they don't fund, but I think so much of the text is that the technologies that are being used are experimental, and new technologies are put into place that are in one sense experimental.

And to decry that, and then to say that you can't put new technologies into place without having them thoughtfully and carefully evaluated, but we won't fund any of that evaluation on a larger scale, I think this puts us in the hypocritical state, which I suspect we would prefer not to be.

The second thing is that there is a great emphasis here on making — and coming to my second point, making information available to patients about the success rate of clinics.

And to the extent that we tell clinics that it is important to use fewer embryos, their failure rate is going to go up.  This is going to reflect in the statistics. 

So the more responsible clinics that use fewer embryos will look worse in just the kinds of statistics that we are collecting.  And again I think that we have to recognize the forces that are driving all of this, and I think not to be honest about the forces is to undermine some of what we are trying to do.

CHAIRMAN KASS:  Mary Ann.

PROF. GLENDON:  Yes.  We are in the preamble, I gather, and the preamble states, or the introduction states that it would be premature at best to recommend dramatic legal or institutional changes.

Since a reference has been made to what is done in other countries and countries specifically with national health insurance, I thought that it would be interesting just to notice that I am reading from a January 11, 2004 summary of recent European legislation on this topic.

Many of these countries prohibit the freezing of embryos, limit a couple to 2 or 3 embryos, and some countries prohibit donations from third- parties, limit in vitro fertilization to heterosexual couples; prohibit genetic testing on embryos; proscribe cloning or experimentation on embryos.

And so it is worth noting that there are a number of countries that do not think it is premature to take more extensive measures than the very modest ones that have been recommended in our report.

CHAIRMAN KASS:  Frank.

PROF. FUKUYAMA:  I guess, Janet, I don't understand the objection, because the FDA regulates drugs.  You know, requires extremely expensive clinical trials that drive up the price of drugs, but the federal government does not fund the development of — I mean, it may in some cases fund the development of new drugs, but it does not — you know, you don't question the legitimacy of its regulation of private sector activities in drug development simply on the grounds of the level of funding, federal funding, for drug development.

So I don't really understand the two are necessarily related.  I mean, if there are serious safety considerations that are raised by private sector activities in this area, it seems to me that the federal government would have an interest in looking at that, regardless of whether it funds these activities itself.

DR. ROWLEY:  But, Frank — I mean — I don't think that is really relevant, because the drug companies after all are able to incorporate the cost of drug development in the cost of the drugs, and I am not aware that any drug company is on the street bankrupt at this point.

So I think that we are talking about activities which — the research for which is funded by patients out of their discretionary funds, and I think it is a totally different matter. 

DR. FOSTER:  I was going to say the same thing.  In principle, what you say is correct.  But corporations have big funds for research.  You pay for it in the drug, but none of these people — I mean, it is a very expensive thing to have in vitro fertilization, but nobody is getting rich out of that.

I mean, if you just look at the incomes, and the doctor's incomes and the nurses, and so forth, which are there, there are no — as far as I know, there is nobody getting or has any excess surplus funds that you could do expensive laboratory or other research.

So I think that — I agree with Janet that that doesn't — that this is one of the rare times which I think that your comment doesn't apply, okay?

CHAIRMAN KASS:  Frank.

PROF. FUKUYAMA:  I mean, Congress just passed one of the biggest new entitlement bills for drug benefits precisely because the requirement for drug testing has driven up the cost of pre- drug development up in this country and people cannot afford it. 

So I just don't see in principle — I mean, it is true that the structure of the ART industry is very different from that of the pharmaceutical industry, but part of the reason that you got this structure of gigantic corporations is precisely because of the regulatory burden that is placed on drug development by the FDA.

So, yeah, you are absolutely right.  It is going to drive up — I mean, some of these things are going to drive up the cost of these kinds of treatments, and they will have to be borne out of the pockets of the people that want the treatment.

But again I just don't see how this is any different from private sector drug development.

DR. FOSTER:  I do want to say also without being — I love the drug companies.  They are making wonderful new drugs, but I don't have the latest figures, but I believe the evidence is pretty overwhelming that they spent more money on advertising and doctors in luxurious parties than they do on research and development.

So, I mean, I think that is a very — it is not fair to say that the cost of the drugs are solely because of regulation for safety on the FDA.  I mean, if you look at these budgets, I mean, they are obscene about some of the things that are done at scientific meetings and so forth.

I mean, that is probably irrelevant, but I had to say that because it gets my spleen up; that when everybody says that because of the drugs the FDA is the cause of this.  I think we ought to be very thankful that we have an FDA that is trying to carefully look over these drugs, and particularly the second level drugs and so forth that go on.

I happened to hear the Commissioner talk this week at this meeting in Texas, and he points out and defends even the approval of second — you know, "me- too" drugs, and drives the costs down, and so it probably — you know, I don't know much about the FDA, but I think that we shouldn't blame them for these costs exclusively.

PROF. GEORGE:  Dan, you have whetted my appetite.  What are these obscene things that happen at scientific meetings?

CHAIRMAN KASS:  No, let's —

DR. FOSTER:  I should not use that term.  The obscenity is gluttony of food and drink, that's all, and nothing to do with anything immoral, okay?  Please do not saddle me with that.

CHAIRMAN KASS:  Let me try to resolve this.  We will certainly take Janet's comments into account in the new draft.  One word on the costs, and the cost was an issue already raised, and we have indicated at least with respect to the call for additional federal activity that the funds ought to be provided as they are now provided to the CDC for any additional activity that the CDC would undertake.

So that this would be an attempt not to pass those costs on, or at least that is our — we are cognizant of that fact.  Let's go from the preamble actually to the particular recommendations and in Section 1.

Welcome to Mike Gazzaniga, who is happily down here where the temperature is only 30 degrees instead of minus 30.  Oh, and Charles, welcome to Charles Krauthammer.  Sorry. 

Section 1, beginning on page 3, we are just beginning to review the particular recommendations on the federal studies.  And since we could go one by one, but let me — and since I think that this is relatively okay, why don't I simply put the whole of the materials from page 3 through page 10; the federally- funded longitudinal study on the health and development implications of ARTs on children.

And we have had very good conversations with the people designing the National Children's Study, and we are hopeful that they will be willing to include this as part of their study.

To undertake federally- funded studies on the impacts of ARTs on women, on the uses and effects of reproductive genetic technologies; strengthen and augment the Fertility Clinic Success Rate and Certification Act with specific provisions on reporting requirements.

And on enhancing patient protection and implementation.  These have been streamlined and changed in ways that I already indicated.  Are there questions or comments on any of these particular items?  Gil.

PROF. MEILAENDER:  My comment is with respect to something on pages 6 and 7.  It is under the enhanced reporting requirements, (b) I guess it is, risks and side effects.

I would like to see us restore a sentence that was in an earlier draft, but is not there any longer.  I don't know whether the rest of you will think it is worth it.  But I preface this by saying that sometimes when you bend over backwards to be accommodating, you simply get kicked.

And that seems to me to be happening here.  I mean, we have before us a news release from RESOLVE about what we are supposedly doing today that is inaccurate in almost every respect. 

And this was one of the stakeholders that we were worried about.  What I would like to see us do is add at the end of that paragraph that goes over on to page 7 a sentence that simply says this is taken from the previous draft.  ART clinics should be asked to provide data on the incidents of adverse effects on women undergoing treatment, as well as on the health and development of children born using ART at least through the first year of life.

I myself don't understand why anyone wouldn't think that was useful information, and that one would like to know.  Remember that all we are doing is asking for information to be gathered that might be helpful in determining what regulation, if any, would be needed or wise to advise.

It seems to me that this sort of information would clearly be useful, and would be worth knowing.  I don't understand why it dropped out, and I myself would like to see it restored.

CHAIRMAN KASS:  Carter, I may need some help on this, but I think I can understand why it is absent.  First of all the clinics do not follow these children once pregnancy has begun.  They are turned over to the obstetricians, and then to the pediatricians.

Second, in order to do that, you would have to have a de facto registry of children born with ART, and there is a great deal of interest both in the patient groups and in the practitioners, to protect the privacy of the participants.

We thought that we might in fact get the kind of information we were interested in from a longitudinal study in which people are tracked not just through the first year of life, but as long as the study continues, and tracked prospectively such that one would simply happen to know that some of the children in the study had this origin.

And that all of the participants would be volunteers, and we would get the information without having to violate these particularly important principles and concerns, both of the patient groups and of the practitioners.  Carter, have I got that right? 

MR. SNEAD:  Yes, I think that is a fair characterization.

CHAIRMAN KASS:  Carter Snead, who is our general counsel, has been the major — in fact, Carter, why don't you take a seat here, because we might need you in addition.   

MR. SNEAD:  Yes, Leon, I think those were — that was a fair characterization of the concerns that were raised, both the logistical difficulties of gathering that information, and requiring coordination with pediatricians and so forth. There is not right now a continuity between the doctors that — you know, the reproductive endocrinologists, the obstetricians, and then later, pediatricians, that would have to be created.

And then secondly there were concerns about stigmatization of these children through the creation of a de facto registry as you outlined.  I think that is a fair characterization. We thought that we would get the same sort of information through the longitudinal study.

And then additionally — and one thing to add about the longitudinal study.  The National Children's Study, if they were to accept our offer to include this information in their project that they are going forward with, they release their data at certain milestones, such that you wouldn't have to wait for 21 years to get the relevant information.

And so there would be sort of a rolling reporting of the results that they would get.  So basically to accommodate the concerns that were raised, and with the idea that the same information could be gathered through other mechanisms, that's why the document was changed the way that it was.

CHAIRMAN KASS:  Other comments about these original

— Gil, do you want to —

PROF. MEILAENDER:  I would just put on the record that that does not seem to me to be a sufficiently weighty reason to eliminate it.  It does seem to me to be information that would be useful to have.

I think the registry language is bogus, and there are plenty of ways to protect confidentiality in our world.  And I can't see much hope for any future regulatory agency keeping close watch on these matters. 

If a body like ours that simply is thinking about what information it might be useful to have in order to know whether there should be such an agency, or what it might regulate, already goes belly up at the first sign of pressure. 

So it seems to me that it is useful information and that it would be good to have.

CHAIRMAN KASS:  On this very point, Robby.

PROF. GEORGE:  Yes, I wonder if the staff has looked into it, or if Mary Ann just happens to know, how other jurisdictions — European countries, Japan — have dealt with trying to honor both of these concerns, the one that Gil quite legitimately raises, and the concern about privacy and so forth.

Perhaps there are models that would be helpful to us.  Do you know?

MR. SNEAD:  As far as the jurisdictions that have the most comprehensive approaches to monitoring and oversight of these reproductive technologies, my recollection is, if it is correct, is that there is no jurisdiction that provides for oversight up to a certain — beyond the stage of birth.

So as far as I know, there are no models that would provide useful examples for how to solve the logistical problems of tracking these children and their families.

And most of the registries that are being created abroad, my understanding is that in France and maybe in Belgium, there are sort of federally- sponsored efforts to track these individuals, and I would have to look more closely at how they go about doing that.

PROF. GEORGE:  Do you know anything about whether privacy concerns have been taken into account?

MR. SNEAD:  I imagine that they have been.  I met with our counterparts at the HFEA in Britain in August, and that seemed to be a concern that was very — that was foremost in their minds was safeguarding privacy.

So I think that they had done that in a way that is satisfactory.  I can't speak to the specific mechanisms that they used though.

PROF. GEORGE:  Well, I would like to request that the staff look into this and perhaps we can satisfy everyone here.

CHAIRMAN KASS:  Okay.  Still on this same point, or are we going somewhere else?  Is it on the issue that we were just discussing?  Mary Ann, is it still on this point?

PROF. GLENDON:  Yes. 

CHAIRMAN KASS:  Please. 

PROF. GLENDON:  I just think it is worth emphasizing how modest the recommendations in this section are.  Nobody is talking about government regulation of a practically unregulated industry.  One is only talking about information so that there can be informed public deliberation of some of these issues, the kind of deliberation that we have in a democracy.

I think that I am just a little skeptical about talk about undue government intrusion, or privacy concerns, when all that is being sought here is information and letting the sun shine into an industry that apparently is bent on keeping its activities from public surveillance.

CHAIRMAN KASS:  Comments still on this?  Mike, do you want to go somewhere else?

DR. GAZZANIGA:  Well, it is related.

CHAIRMAN KASS:  Please.

DR. GAZZANIGA:  I am continuing to read this section and to be able to think about it, and it really comes down to what we are saying, is that we are trying to recommend that epidemiological studies be carried out in IVF.  Why don't we just say that?

Federally- funded, and we would recommend that federally- funded epidemiological studies be carried out on IVF, period, and not try to play the game of what all that means.

There are epidemiologists who know how to do this, and they do it all the time, and for us to try to prescribe these various this and thats is probably not necessary, and I don't even know that it is particularly informed by the subtle science of epidemiology.

So — I mean, what the intention is, is simply to carry out that sort of activity, but let the sun shine in as Mary Ann says, and there are procedures for — well- established procedures for doing that, and I recommend that we just recommend that.

CHAIRMAN KASS:  Rebecca.

PROF. DRESSER:  Well, I think we are writing this document not just for researchers, and so I think it is worthwhile talking about what the kind of information is that we would like to see to the ordinary person.

I mean, if you just say do epidemiological studies, the ordinary person won't be able to understand that, and I guess I want to second the consumer protection value of this information.

This kind of study would enable people who have children this way to know if there are certain medical problems that crop up more often, so that the pediatrician needs to be looking for them.

This really could promote the health of these children, and so it seems to me that consumer groups should welcome a call to produce more of this information just so that their constituencies can make better informed decisions, and they are usually people who are very concerned about the well- being of their children.

And this kind of information would enhance that ability to show concern for their children.

CHAIRMAN KASS:  Janet.

DR. ROWLEY:  Well, I noticed that Kathy Hudson is here, and I wonder with regard to the question of what other countries do, because I am under the impression that they are some large studies in this matter, whether Kathy could answer or has any information, or —

CHAIRMAN KASS:  Kathy, would you like to respond, if you wish.

DR. HUDSON:  With respect to the question of post- birth surveillance of health of ART children, in other countries I think the situation is quite different, where there are national health records in many countries, and national birth records in many countries, that can be linked.

So you can do studies, albeit retrospectively, of large cohorts of children because of the existence of these records.  So I think where we see the best data is in fact in countries where you have that kind of record system, which of course we don't have in the United States.  Was there another —

DR. ROWLEY:  Well, the question is whether there are any results or whether these studies have a time in which they are going to do the analysis and publish them?

DR. HUDSON:  The European Society of Human Reproduction and Embryology has been doing a very large prospective trial looking at children's health from ART.

And they are now following kids up to about seven.  I think they have reported data on the health of children out to about seven.  I think the existence of that data doesn't negate the need for additional research in the United States, because techniques do vary.

DR. ROWLEY:  Thank you.

CHAIRMAN KASS:  Thank you very much.  Dan.

DR. FOSTER:  Michael, I thought that it was very attractive from this standpoint to try to bond in on the study that is going to already be done.  I mean, that you are going to follow these, and so it seems to me that the modesty of this is also very practical, and the information that we really want to know would come out, and particularly since they are going to have interim reports.

I mean, just look at the Framingham Study and things like that.  I mean, we really need to know whether if you take a cell out for genetic diagnosis and so forth whether that does anything or not.

I think that everybody would want to know that, and so I was really quite enthusiastic about not coming up with some — to say somebody else to do an epidemiologic study, and let's say an agency such as the CDC or something.

I like the idea of trying to just add on — because it is a monumental thing to follow a hundred- thousand kids.  I mean, you know, people drop out of these things all the time, and so I thought that this was a great idea myself.

DR. GAZZANIGA:  Well, let me just comment on that.  I have no problem that the epidemiological analysis goes on within that study.  That study as you know has not been funded.

And they are looking to tack this on to try to get it funded and there are inherent problems with these studies because of the drop out and because you start to dilute the number of factors that you are looking at, and then you can't really say statistically about any of them, et cetera, et cetera, et cetera.

So I think that it is fine in the sense — I mean, in the sense that it sounds right, but in some sense just to recommend funding of IVF might allow it to go forward when maybe that mammoth thing won't go forward.

So you might get locked up in getting what you want to get done here by completely attaching it to that study.  That is just a very practical point.  But that is what we are talking about. 

We are talking about getting it done somehow, and I think just saying it is sufficient.  I mean, then we don't have to get entangled in all these subtleties.

DR. FOSTER:  Well, I heard what you just said about maybe this would enhance, but maybe the sentence that one would add here would be something like that should there be a failure of funding of the child health study or whatever it is called that we would recommend an independent study of the children be funded because this is such a critical issue.  Maybe just a sentence like that added would be helpful.

CHAIRMAN KASS:  Also, let me just say quickly, Mike, that one could preface this with the generic comment that you make, but the particular things that have here been identified are in fact and do grow out of the analysis that we haven't recirculated at this time.

But that we have identified different kinds of areas for an epidemiological study, and we have also talked about the already existing reporting requirements and suggested that there might be some additional things that could be done to augment the publication of data already collected.

So I do think since there are various possible target audiences for this that there is a certain amount of specificity is, I think, helpful.  But I am prepared to — well, these are the kinds of information that we are somehow specifying here.

If we are going on too long about it,and you think it could be streamlined, we could certainly do that.  Anything on the particular concrete substantive things in that first section?

DR. ROWLEY:  As a point of information, Carter, I have been told by individuals with whom I have been discussing this matter that there is in fact a federal website that is devoted to information about ART, and it is my impression that this is the only federally funded site on any medical procedure.

MR. SNEAD:  I think what you are referring to, and you can correct me if I am wrong, is the CDC's ART surveillance website, which — is a web publication of the document that also comes out in hard copy that is basically required by the Wyden Act, to outline the success rates and various points of analysis.  Is that what you are referring to?

DR. ROWLEY:  I assume so, since this is information that I have gotten from discussions with others.  We didn't go into great detail about this.

MR. SNEAD:  Right.

DR. ROWLEY:  But it is pointed out that there is no other federally- funded website about any medical procedure. 

MR. SNEAD:  That's interesting.  I was not aware of that, that there were no other federally- funded websites.  I know that the CDC has other websites relating to other medical concerns, but I don't know how that bears on your comment.

But that would be news to me if that were the only federally funded website that relates to a particular procedure. 

CHAIRMAN KASS:  Shall we proceed to the second section?  Robby.

PROF. GEORGE:  One more, Leon, on that question of the possibility of tracking the numbers of embryos that are created, their use and disposition.  My impression is that it is actually very difficult to get reliable information about just the sheer numbers of embryos that are created in the industry, and how they are used, and their final disposition.

If that is true, is there any proposal short of the one that was in the original draft for enabling that to be done?  Or if we don't propose anything here, will it just be continued ignorance about the facts?

CHAIRMAN KASS:  We made a decision simply to remove that section.  There has recently been a study, the RAND study, which has disclosed the numbers.  It would be possible to make a request to produce aggregated data from the various clinics without identifying which clinics.

I mean, the clinics are rightly concerned that publication of such data with their names attached to it would in fact enter into the political turmoil about abortion politics and the like, and they want to protect the privacy of what they do.

There is a case to be made that the Nation as a whole might like to know the answer to just simply the quantitative data.  But we recently had a study which to the best of people's knowledge, indicated there were roughly 400,000 embryos in cryopreservation.

And I guess the question is what difference would it make if we commissioned a study which produced the number of 600,000, or 300,000, or 1 million?

It seems to me the number — we know that there are lots, and since this is not — since we don't have a policy here to recommend on what should be done there, it seemed to be to call for that kind of data collection at this point, knowing that the number is very large already, seemed gratuitous, and off the main point.

If there is strong feeling that this should be restored, I am not unhappy to restore it, but it didn't seem to me to be essential to what we were talking about here. 

PROF. GEORGE:  Well, if we could get the information another way, I would be very open to that, but I think that the information is potentially relevant to public policy mix and the kinds of people that we are attempting to serve. 

I think it is.  I mean, as we go forward just being able to compare what goes on here with what goes on in other jurisdictions that have other sorts of regulatory schemes or have regulatory schemes at all, I think would be potentially at least very valuable.

CHAIRMAN KASS:  It certainly would not hurt anybody to know the answer.  But let me simply ask, is there anybody who would object if there were simply a restoration of some kind of request for information on the number of embryos created and stored? 

Do we regard that as an important piece of information that people want to know in this area or not?  Yes, no, maybe?  How many think that this is information worthy to be had and that we should restore something on this?

(A show of hands.)

CHAIRMAN KASS:  How many think otherwise?

(A show of hands.)

CHAIRMAN KASS:  We will think about it.  I mean, there was a certain — and we will talk to the individuals, but there was a certain sense that these recommendations were to be as much as possible the recommendations that were rested on those things about which we could agree, and part of the thing is to show that people have differences of opinion on some of these matters, and find a basis nevertheless to speak in common on things that are dear to us.

I won't discuss — I think we have noted the people who have reservations about this.  We will pursue that, and if — and we will reach some resolution on that, and you will be informed rather than try to fight it out here.  Is that agreeable?  Janet.

DR. ROWLEY:  It is not on this point, but it is on page 8 and 9.  Are we still on those pages?

CHAIRMAN KASS:  Fine.  Yes, we are still in this section.  I am going to try to budget our time to make sure that we don't lose out on the sections that might take us longer than this.  But, please, Janet.

DR. ROWLEY:  Well, again, in discussions with people more knowledgeable than I, it has been pointed out for Section E, the adjunct technologies, and our concern about ICSI, that in fact about 5 percent of apparently normal sperm failed to fertilize an oocyte.

And at least right now, given the fact that there is no funding to understand these problems, we can't — I mean, the individuals involved in this can't distinguish the normal from those that have various other things that can be identified.

So, you see, we have talked here and commented about the fact that ICSI is used in individuals, even those who do not suffer from male infertility factor, and again with the pressure to have positive results, both from the standpoint of patients for whom this is a painful — or for women for whom this is — the whole process is a painful procedure, they use ICSI to increase the likelihood that you will actually get some embryos from the procedure for the women.

So we are saying that the industry is being irresponsible by using ICSI when they don't need it, but the matter of fact is that you don't know for those who are the 5 percent who they are, and therefore, many clinics in order to make certain that there are some embryos that are developed, do ICSI when it may not be needed.

But, you see, that doesn't come through in the text that is stated here.  So I think that we should be a little bit more — either indicate that there is this 5 percent where it would be unsuccessful, or maybe modify the text here not to be quite so critical as we are of this procedure. 

CHAIRMAN KASS:  If there is an implied criticism, the implication will be removed, and the request is simply for the reporting of the data and the indications, and if there are additional indications, then of course we should note that.  That is a good point, and we will fix that.

Look, I am mindful of the clock, and let me do something slightly out of order.  I suspect that we need more time to discuss Section 3 than Section 2, Section 2 being recommendations to the professional societies and practitioners.

And let me simply go out of order and do Section 2 last to make sure that we don't wind up at 5 minutes to 12:00 with only 20 minutes or so to do Section 3.  So, we will do Section 2 last.

Let's turn to the targeted legislative measures, pages 13 through to the end.  I repeat that these have been pruned, and things that were contested last time have been removed, and certain sorts of other difficulties ironed out. 

And maybe we should keep our attention to the specific proposals first, and worry about the fine tuning of the rationale, and the discussion later.  Page 16, the transfer, proscribe the transfer for — by the way, let me say just — and in this document I apologize, but it doesn't have this point that was made the last time in it.

And these suggested targeted legislative measures were meant to be temporary.  It is indicated in passing that that is the case, but we don't say that there should be a fixed time on it, and that is for review, and that was one of those suggestions made in the Council meeting last time and that will be added to the final version.  So these we are targeted legislative measures of a temporary sort, at least until additional discussion proceeds.

Then to page 16, proscribe the transfer for any purpose of any human embryo into the body of any member of a non- human species, and to prohibit the production of a hybrid human- animal embryo by fertilization of human egg or animal sperm, or an animal egg by human sperm. 

These are the two things that survived.  There were more things in the previous version.  Dissents, objections, comments?  The Dean from Dartmouth.

DR. GAZZANIGA:  Oh, geez.  It is cold up there.

CHAIRMAN KASS:  It is very cold.

DR. GAZZANIGA:  You know, it is all sort of — you know, this flows from the dignity of human procreation and all of that, and I keep thinking of G.K. Chesterton's remark to his son as he went off to college.

He said that with respect to sex, son, it is a ridiculous posture, and I always get confused about where we launch from here.  So if you look at — I mean, what everybody wants is a child out of any deal, right?  A beautiful child.

And that normally occurs in 98 percent of the time through mechanisms that we all know about, and love and respect.  But frequently it occurs through going to a lawyer's office, and figuring out how to pay money to go adopt a child.

And I don't know.  Maybe biomedicine is going to come up with a mechanism where a husband and a wife can fertilize an egg, and the woman can't have it implanted because of certain medical problems, and you can think of a cow as a big tissue culture to allow the baby to grow. 

And what happens is that when the baby is ready for birth the family seizes on the baby with all the love of any parent and life goes on.  So, you know, we take — a lot of these things that have been put in there have been set up with this crazy humanzee notion and that sort of thing.

And really I think, if we start fiddling around with this language, that we may be stumbling upon possible future biomedical advances don't seem very normal after a while. 

So I am concerned with when we start introducing language like the first item there. 

CHAIRMAN KASS:  Comments?  Rebecca.

PROF. DRESSER:  I like the way this is set up because it is a temporary moratorium and it just shifts the burden.  In a sense, it says all right, if you come up with something that seems to be covered by this within the time frame of the operation, then you have to make your case and explain why — you know, certainly it is safe, and needed, and other alternatives don't sufficiently meet the need, and that certainly that practice would be something that ought to be publicly discussed before it went forward.

So I do think that the posture of this, that it sets up, the procedural posture, leaves room for situations where a new technique might develop that does seem to fall under this, and might have a reasonable rationale, and there is still the opportunity to present the case, and certainly the research on that sort of a procedure would probably last longer than these provisions, in terms of effect.

You know, they would go out of operation and then there would be a new discussion about whether a more specific prohibition or provision were needed.  So I think the way that it is constructed, it is sufficient to handle innovations like that, or other things.

CHAIRMAN KASS:  Are there comments on this one?  Janet.

DR. ROWLEY:  Yeah.  I assume in the staff's discussion with representatives of the organizations that have a direct interest in this, and that these were items that did pass their scrutiny and have been retained.

In my discussions with other individuals, they are concerned that it appears to paint the ART community in a less than ethical light by implying that these things are something that the scientists in the ART community are preparing to do, and so we have heard certain discussions about some things that have been done in other countries, but at least as far as those practitioners in the States, they have real concerns about even including these things because in their view this is not something that they are planning to do.

DR. KRAUTHAMMER:  We could take are of that by adding the phrase, "without prejudice" and "without implication," and that would take care of that, I think.

DR. ROWLEY:  But if that is the case, then why do it at all?

DR. KRAUTHAMMER:  Because — not because some people are doing it today, but because it is something that we believe is abhorrent and ought to be at least not permitted until people make the case otherwise.  It seems rather simple.

CHAIRMAN KASS:  In fact, the argument that we — I am not sure, Janet, that it would be fair to say that everything that survives here has passed the scrutiny and claimed the approval of the people with whom we have consulted, that is not our task.

And our task is to learn from them, where we have done things that we ourselves would recognize as unreasonable, or be educated by them about things that would place undue burdens on their practice.

I don't think that there is any implication here that the members of this profession are unethical or unscrupulous.  It is an expression of the community's support at the moment to try to set certain boundaries, and one of the ways in which the professionals could in fact show that they are not under suspicion is to endorse these provisions.

I mean, these are exactly the sorts of things that the responsible practitioners ought to be able to say and be offered — this was a suggestion that we made in conversation with representatives from ASRM.  We have a stake, we would suggest, in making sure that everybody understands that the profession has the highest ethical standards, and doesn't mean to ride roughshod over the boundaries that the community has established.

So we are trying to do those sorts of things for which they might worry about Congress doing anything because they don't like that.  But we have tried to devise those kinds of very modest things that ought to appeal to just about everybody, other than those people who don't give a damn.

So there is no imputation that there is anything irresponsible about practitioners or their society here.  Paul McHugh.

DR. MCHUGH:  Well, I may be saying something at once obvious, but in relationship to this first thing, I have two reasons for wanting to have it included.   One of them is simply the "ugh" factor. 

I don't think that I can speak to the ordinary person in America and say that we think that babies should come from cows very simply, and so therefore the burden would be for the scientists to say that this might be okay.

But I have a more practical concern and reason for wanting to see this.  I believe that it is not outside of anyone's imagination that the process of putting an embryo into an animal to let it proceed for a while would soon become a process searching not for a live baby for these folk looking for a baby, but for ultimately the harvesting of those embryos for their bodily parts; their kidneys, their hearts, and the like.  And I find that repugnant, too.

CHAIRMAN KASS:  Frank, and then Dan. 

PROF. FUKUYAMA:  Well, this just follows on the last couple of comments, and this is actually, Mike, more of a response to your written comments than to what you just said, but I don't think that what you are defending is necessarily the dignity of — you made the comment that human reproduction is not all that different from the mammalian reproduction more generally. 

But I think what is being — you know, you can at least say that each species has its own reproductive rules, and evolution has designed them to be an integrated whole.  So that a baboon presumably will not do very well if implanted, or as a baboon won't do well if put in a human uterus. 

And I would think that there are huge medical risks if you create an embryo that has got, for example, animal — you know, mitochondrial DNA, and if you — and I am sure that there are all sorts of things in the developmental process that go on within a uterus that are specific to a human uterus.

And so again this just reinforces the point that there is a huge burden of proof that needs to be met before you start violating what evolution seems to have designed as this fairly integrated reproductive processes.

CHAIRMAN KASS:  Dan Foster.

DR. FOSTER:  I just want to make a small point in response to Janet's.  I don't know who you have been talking to, but I am not very sympathetic to the view that this might be in some sense a judgment on the ethical procedures.  Let me just turn to the scientific community already, and the protection of human resources.

The scientific community found it extraordinarily abhorrent that some of our greatest universities, and some of our very best genetic people about deaths that have occurred doing things that nobody thought should have been done.

I am not very moved by somebody who is in the ART saying, well, you are impugning our integrity when already we know that in the greatest of our universities, and in the whole scientific community — well, I can't say whole, I don't know that.

But I can tell you that universally condemned — and I not going to mention the names — the things that were done here.  So I don't think we ought to be too worried about somebody's concern about moral things when we know that the very best scientists that we thought — well, I don't want to get started on this, but we need to assume that because we can do certain things that they are going to be done, and not just in rogue private laboratories.  But in the university laboratories of the highest things.

So I am very much in favor of saying let's don't do crazy things.  I mean, I don't know what cow uteruses do, but I know that some people think that prion disease, for example, may in some sense be contagious. We know that cattle carry E. coli, 25% of which are type O157 H7 that may be fatal from HUS ( hemolytic uremic syndrome) from eating insufficiently cooked hamburger. So it is a modest thing to say ' lets don't do crazy things that we can do when we don't need to do them' and I feel pretty strongly about that.

And as I said, I don't want to just hear somebody say, well, we are impugning somebody.  We have to be very careful about what we do.

CHAIRMAN KASS:  Anything further on these?  Do you want to move on?  Let me make a procedural observation, because Mike — and I don't know that you would regard all of these answers as a satisfactory response to you, and I don't want to put you on the spot. 

But I am interested in going through all of the comments, and if there remain — our aspiration was to produce something that we could all agree to, but if it turns out that that can't be done, then we will be left afterwards with trying to sort this out.

And we will figure out a way to handle this either by removal or perhaps by allowing the expression of individual dissent in a very strong way on whatever it is.

This is to take the burden off of Mike from saying here and now, okay, you guys have persuaded me.  I doubt that is the case, and I would like to at least see where we are on some of the rest.  Is that okay, Mike? 

DR. GAZZANIGA:  That is very kind of you, Leon, and you are exactly right.

CHAIRMAN KASS:  Okay.  Let's move to the second.  This language has been changed to make it unambiguous; to prohibit the transfer of a human embryo produced ex vivo to a woman's uterus for any purpose other than to attempt to produce a live- born child. 

And the grounds of this have been laid out in the paragraph before, but what we are concerned about is the correlate to the previous one.  If human embryos go anywhere, they go into human uteruses, and if they go into uteruses, they go into human uteruses, and what goes into a human uterus goes only for the purpose of producing or trying to produce a child. 

This I think the last time around had not even a whimper of dissent.   Are we all right? 

DR. ROWLEY:  Just as a point of clarification, I assume that this language doesn't really prohibit the use of PGD to select for an embryo that might be appropriate for some other purpose, because that embryo is selected in general to go to full- term.  So that is not covered in this.

CHAIRMAN KASS:  This solely has to do with for what purpose may you — the previous language was to initiate a pregnancy, and that was found to be — it was obscure and it raised all kinds of worries that were unnecessary, and so this is in effect to start a pregnancy by the transfer of a human embryo conceived or produced ex vivo for any purpose other than to yield a child. 

It says nothing about what is done with embryos outside that don't get transferred. 

DR. ROWLEY:  Or before the selection of the embryo being transferred.

CHAIRMAN KASS:  It says nothing about that at all.  This next provision was one that caused a lot of trouble, but I think we have found with one exception, and I can call attention to the problem in the language now, but the one about children.

I think we have found a way to express this that was satisfactory to the vocal disputants of the last occasion, with the important exception that the presence of the word "and" on the top of page 18 seems to imply that in order for something to be ruled out it has to be guilty of all of those three things.  That doesn't really make sense.  I think the language should be "or" and the reason that we have listed it this way is so that the footnote could operationally define in one footnote exactly what it is that is meant. 

Prohibitive attempts to conceive a child, footnote, and by definition that means to create ex vivo an embryo of this sort with the intent to transfer to a woman's body to initiate a pregnancy.  Prohibit attempts to conceive a child by any means other than the union of egg and sperm by using gametes obtained from a human fetus, or derived from human embryonic stem cells, or by fusing blastomers from two or more embryos.  These were under discussion the last time.  Michael.

PROF. SANDEL:  Well, I think removing the "and" so that it is clear that we are not asking Congress to prohibit some bizarre compound activity that would never arise is a good thing.

But I am not sure that "or" removes the ambiguity altogether, because it could be read as proposing that Congress prohibit one or another of these three things.

So what I would urge is that we remove the ambiguity by simply adopting and by repeating the verb clause for each of the three bullet points as we have done with all of the others, this may seem like a semantic distinction, but I think that it is important for reasons that we could pursue, and that came up last time, but simply say prohibit attempts to conceive a child by any means other than the union of egg and sperm, with the asterisk and the footnote.

And then repeat that phrase in each of the two other proposed prohibited activities with the same asterisk and with the same footnote. 

CHAIRMAN KASS:  I don't see any problem with doing that.  We were — quite frankly, this was one of these places where footnoting and simply the questions of the mechanics of getting footnotes on the page, and repeating footnotes, suddenly produced a way that you could probably do this with one footnote, and the thing was restructured. 

But we are perfectly happy to restore the less ambiguous way and have the same footnote referred to three times or have it three separate times.  It is not a problem.  Are we okay on this?  Difficulties?

(No response.)

CHAIRMAN KASS:  We come to the fourth set of recommendations, pages 18 and 19, and here once again this may be contested.  This recommendation, these recommendations, do not say anything about the licitness or illicitness of embryo research as such.  But even the people who would be or who would prefer that there be no embryo experimentation, but recognizing that it goes on, are willing to join with others.

In fact, the minority position in the cloning report did call for regulation of this, and setting an upper boundary, that there should be some kind of upper limit on the age of embryos available for research, at least at the present time.

And that this is an attempt to suggest the prohibition of the use or preservation of those embryos that are already being used solely for the purposes of research beyond a designated stage of embryonic development, and we left it to the Congress to find its date.

We suggested the range, and then as a result of a long discussion the last time, and what was left of the commercial matter was to prohibit the buying and selling of human embryos.  The gametes part of that as you will recall was in there last time and is not at the present time. 

DR. KRAUTHAMMER:  Leon, I think that I might want to include the range that we have considered, the 10 to 14 days, in the body of it. 

CHAIRMAN KASS:  In the body of the recommendation?

DR. KRAUTHAMMER:  Yes.  I am a little wary about leaving it entirely up on the air, because it would allow — I mean, if we are assuming that this will go to Congress, and there might be pressure to allow higher upper limits, and I think most of us, or I think all of us would agree that the upper limit ought to be within this range.

And I think it would be helpful to Congress to have that as a guideline.

CHAIRMAN KASS:  As a guide posture, yes.  Any objections if we put that into the text?  I mean, they are obviously free to ignore all of this, or free to ignore that, and once again this is for the time being recommendation, and even our representatives from BIO said that they would for the time being favor such an upper limit if I am not mis- remembering that conversation.

We might even have a fair amount of public support on this as well.  Are there any objections on any of this?

(No response.)

CHAIRMAN KASS:  We are left with the patenting matter, and I think that people probably know that — if I can get my cheat sheet here, that the House — that this recommendation might be rendered moot by developments in the current session of Congress.  The House of Representatives has included an amendment to the Commerce, Justice, State Appropriations Bill for Fiscal Year 2004 that would preclude the Patent Office from issuing a patent, "On claims directed to or encompassing a human organism."

And the Patent Office has supported this amendment, and the House — the Senate and House conferees have agreed to include this amendment with some explanatory language in the final version of the bill, but the Senate has yet to vote on the bill, but may do so as early as next week.

If that in fact happens, we can simply delete this provision as being rendered moot.  Michael.

PROF. SANDEL:  Is there any good reason that we have for using the word, the phrase, human embryos or fetuses, instead of the word that is in the legislation that you just read, human organism?

CHAIRMAN KASS:  I see no reason not to even prefer it; to encompassing human organisms at any stage of development I think would be —

PROF. MEILAENDER:  I don't see any reason not to prefer it.  I think the reason that it is here is that it came immediately under the section on respect for early stages of human life. 

And that is probably the reason, and it would need to be clear that it was not a part of that section if the language were changed. 

DR. KRAUTHAMMER:  What does organism add that embryo or fetus would not?  I mean, what are we losing by using embryo and fetus?

PROF. SANDEL:  I don't know the legislative history that led them to adopt organism.  I would be interested to know and to consider that before we decide what language makes the most sense to us.

CHAIRMAN KASS:  Charles.

DR. KRAUTHAMMER:  If it is a question of just matching the language, then I have no objection.  I was just wondering whether there is a substantive difference.  I don't really see any other than organism might mean a full human, which would be an anti- slavery provision, which would be nice, but it is 160 years a little bit late.

So I had no objection if it is just a matter of procedure, but I would be interested if there is an actual difference here. 

CHAIRMAN KASS:  Carter, please. 

MR. SNEAD:  I was just going to add a point of information on the legislative history to speak to the evolution of the language in that particular provision.

In the version that has been tentatively approved by the conferees, they have included in the language now — they have agreed in principle to include language, a colloquy between two members of the House of Representatives to clarify, because there was some question about what the word organism referred to, they have now included a colloquy and some explanatory language from the manager's statement that clarifies that they are referring to embryos, fetuses, and so on, and so forth. 

So this, just by way of explaining or responding to your curiosity about the legislative history.

DR. FOSTER:  My question is —

CHAIRMAN KASS:  Carter go ahead.

DR. FOSTER:  Well, I have not heard about this, but does this imply — does this affect things like genes from humans and so forth and have they been patented?

MR. SNEAD:  No. The explanatory language in the amendment is very similar to the explanatory language in our statement here, wherein we say that the language of any such statute would need to take some care not to exclude from patentability certain things, the likes of which you have described.

And the explanatory language in the manager's statement does precisely the same thing.  It says this is not meant to exclude patents on even stem cell lines and gene sequences, and so forth. 

PROF. SANDEL:  Do we know why they changed it, the language in the law, from embryos to organisms?

MR. SNEAD:  My understanding of the evolution of the current language is that Representative Weldon from Florida included this language that was quoted by Leon. 

When it got to the conference there was some negotiation of some possible addenda to further explain what the language means, and the result, which has not been agreed to formally, but has been agreed to in principle, is to include explanatory language.  So they began with organism, and now they have added this explanatory language, and there was some negotiation about what that language meant. 

PROF. SANDEL:  Would it be possible for us to get copies of that legislative record that we could — in case there are reasons that have not occurred to us about the significance of the choice of the term organism?

CHAIRMAN KASS:  We will be glad to do that, and in fact I was going to recommend that we do that and study this matter before agreeing to the final language, if indeed if has not been rendered moot as a result. 

MR. SNEAD:  Just a last — I'm sorry to keep interrupting, but the last point of clarification is that this is in the context of an appropriations bill also, and the precise language speaks to allocation of funds for the issuance of patents on certain things. 

CHAIRMAN KASS:  I see.

MR. SNEAD:  It is not merely a statute that proclaims these provisions.

CHAIRMAN KASS:  So this is a rider on an appropriations bill and lasts just as long as that bill?

MR. SNEAD:  That's exactly right, and in that way it is similar to the Dickey Amendment.

CHAIRMAN KASS:  Then we are it seems to me still in business here on this, regardless.  Was there someone with a hand that I failed to recognize here?  We will get this information and study the matter, and we will advise you as to what we have learned, and then reformulate exactly.

Am I right in saying that with the exception of Mike and his concerns which may extend not only to the comment that he made, that the rest of us are all right with the formulations that are here, and that there is certain language to be cleaned up.

We want your line edits on the rationale and justification.  We will take the changes in the third point as Michael suggested, and we will do what we need to do to clarify this last point on the patent thing.

Let's go back and look at the recommendations addressed to the professional societies, and practitioners.  Suggestions to improve informed decision-making, and encouragement to treat the children who are the products of ART as relevant patients.

Some encouragement to improve the enforcement of their own existing guidelines, and improve procedures for the movement of experimental procedures into the clinical practice, and to create and enforce minimum uniform standards for the protection of human subjects and the invitation that they join the kind of activity we are engaged in here as setting thereforth their own self- imposed ethical boundaries in the name of their own professions. 

These are the things that we think all people who are members of our society shouldn't mind, though.  Obviously, we have discussed these things, and I think that some of these things will probably simply be welcome. 

They are mostly hortatory, and we would like to think that they would receive serious consideration.  We have every reason to think that they would be considered seriously even if there is disagreement.

And I myself don't see any reason why we shouldn't at least suggest these things for their consideration.  But I think that this was the sense of the group the last time.  Some of these items may strike you as not warranting inclusion, which is why we brought them before you again. 

Comments or questions on any of these items?  Janet.

DR. ROWLEY:  Well, in line with my earlier comments, and so I recognize what Dan is saying, I think that we should be more cognizant of the fact that most of the physicians and scientists working in ART are in fact committed to ethical practices, and are responsible individuals.

And so I would like to see the preamble to this section at least include a sentence that we recognize that they are individuals who have the health and well- being of the woman, as well as the child, as a high concern, and I think that that should be stated.

It has been suggested to me that under Item A, improved informed decision-making, that in fact the standardized forms for consent, et cetera, may be difficult to develop because there are certain State laws that are different amongst the States, and therefore trying to resolve the differences might cause problems.

And Rebecca or somebody would know better than I whether there are really such State laws that might make a uniform consent form impractical.

CHAIRMAN KASS:  Rebecca, please.

PROF. DRESSER:  One thing to do would be to — I think at one point it said model.  Basically, I think the idea here is that there should be a basic set of substantive information that is provided to all prospective patients, and then clinics — there will be information that should vary from setting to setting, just because of various features of the clinic, and so forth.

So I don't think this is saying that there is one form for everyone, but that the basics would be there, and then it could be tailored to the specific setting.

And I am not aware of any — I mean, there may be some laws setting forth something like, well, perspective patients should be told the success rates, or something like that. 

But I don't think that there are any laws that would conflict with laws in other States.  So I don't think it is a serious problem. 

CHAIRMAN KASS:  Also, I think one could say that at least one of the patient groups that we have spoken to is quite interested in this thing.  I think more could be done here to get this information out.

So it is not just giving consent, but it really is to make the decision-making more informed, and we have been guided in part by Rebecca, and in part by requests from some of the patient groups that we have spoken with on this point.  Mike, please.

DR. GAZZANIGA:   Paul, help me with this.  Let's say on page 11 that we were going after psychiatry, and the first sentence would read, "The psychiatrist should take measures to ensure the health and safety of all participants after they leave the psychiatrist's care and his building."

I mean, isn't this sort of a harsh way to introduce the notion that maybe the ART physician is raising somewhere?  All you are pushing here for is that we would like some epidemiology to make sure that — well, I don't get the harshness of this paragraph, and I would just think that — and I am trying to imagine a physician being told, lectured to, about how they might not be caring correctly for the medical procedures that they administer.

DR. MCHUGH:  Well, it is interesting that you mention psychiatry, and the long term effects, and effects of other people that are involved in the enterprise, because there are laws as you know in the State that — in all the States now, that if a psychiatrist in caring for one patient discovers that that patient might be a danger, or a serious danger to some other patient, or some other person, that it is intended upon that to break the confidence of this procedure, and they are told in no uncertain terms in the courts that they will be held responsible for any damage that could be done to that third- party.

So to some extent, Mike, that kind of harsh language for psychiatrists in particular is already on the books. 

CHAIRMAN KASS:  Let me also — sorry.  Let me respond to the specific content here, and if the language seems accusatory, we will change it.  What is behind this is this. 

And this came out in the conversation with Sandy Carson and Sean Tipton, that for the most part the people who practice ART, the clinicians, regard their patients as the infertile individuals as patients.

But what is recognized clearly is that — and in fact that is one of the concerns that animates this entire report, an interest in the children who are produced, and who are not yet there. 

And yet those children are affected by the things co- incident with their conception.  And the question is whose responsibility is it to start to pay attention to those things. 

Very interestingly, after Sandy Carson made her own presentation here, she reported that the society was beginning to produce new collaborations with the Association of Pediatricians, and that the concern for the children produced by these procedures was now increasingly part of their own concern.

Up until this point, they have said quite frankly that our clients are the infertile couple, and somebody else looks after the children.  But this is one of those areas in medicine where in fact the treatment of these individuals means the production of another individual who is joyously present, but nevertheless somehow at risk, and one wants to somehow address the concern for those participants who have so far not been considered part of the domain of concern.

How to do this given that the reproductive endocrinologists are not going to care for the woman through her pregnancy, and are certainly not going to look after the child is a difficult matter, but we have at least encouraged the society to think about that individual who is in fact one of the participants, though he or she is not yet spoken up.  Bill May.

DR. MAY:  It seems to me that there have been two points made.  One is the question of whether if you offer comments by way of encouragements to professional society, you are tainting and offering accusatory judgment against them, and it seems to me that Charles' point that in fact your concern was protecting that community, and not simply tainting them by the development of advisory here.

But, second, there is an additional problem of disaggregation of services in health care.  So it is not simply a question of use- abuse, and to worry about abuses. 

The problem with the disaggregation of health services is a general problem, which is more acute here, because you have got the services of somebody assisting in reproduction, and then you punt on to somebody else.

And it is compensating for this general problem in our health care system by suggesting that those who offer one service ought to have sympathy to the problem of continuity in health care, which in this case includes a new human being. 

And so it is not simply charging against abuse, but enlarging the sense of responsibility as it bears on a general problem, which our health care system faces in the balkanization of services.

CHAIRMAN KASS:  That is a very nice point, Bill, and I think the rationale for discussing this could certainly include those points.  Dan.

DR. FOSTER:  In the first place, I want to agree that we ought to get the harsh things out, and I certainly — and maybe in your sentence we ought to say that we know that the vast majority of all physicians in ART are highly ethical and so forth, and I think we ought to use vast, and this is not an attack on anybody.

But here — well, I am puzzled, along with Bill May.  I mean, medicine is a continuity, and we do pass on.  I mean, when you have your coronary bypass surgery, then it goes on to the cardiologist.  And the bypass surgeon is not — I mean, he cares about the patient, and wants to be informed about the patient, but I really don't see what the person, the physician who is inducing the pregnancy, what that person can do once the pregnancy has started, or if the child becomes born, and the pediatricians, and then the obstetrician passes it on.

And then when you are 16 or 17 years old, then the pediatrician passes the patient to the internist, or whatever.  I mean, I really don't — I have been troubled about what we are trying to accomplish here.  I mean, in there, and I think it would — I guess you could say that you can improve communication and let the obstetrician know if there are complications leading to abortion and so forth, so that there is new information.

But I don't see — and then you could say that the internist passes it on to the geriatrician when somebody gets to be 65 or something.  I mean, medicine is a continuity, but it is also in practice a discontinuity, and I don't see how what we are saying to the ART people that they have a responsibility once they have done their duty and done their work.

I mean, I think this is — and it may be a little bit superfluous to it, but —

CHAIRMAN KASS:  Let me try, Dan, if I might.  I mean, I take your point.  I think that the reason that this comes up at all is to repeat this is a peculiar branch of medicine because the treatment involves the creation of a new individual.

When we get passed from our cardiologist to our urologist, to our internists, it is the same person who goes along.  Here what is being passed on, though invisible, is a being who is both the product, but also the patient, of this procedure, and we don't want to somehow say, or at least at the moment no one is going to say that when you ask, well, the ethics of experimentation, or the ethics of practice in the ART clinic somehow has to take into account the rights of the embryos that are created.  That is not going to pass.

But it is sort of odd to say, to hear people say, that all of the participants in ART are the doctor, the man, the sperm donor, the egg donor, and the woman who carries the child. 

There is another being that is being produced here, and becomes eventually a being, or whatever it is.  And to begin to think about one's activity, mindful of the presence of that eventually to be produced being I think affects also how you practice.  It means that you begin to cooperate in the longitudinal studies on the well being of those children, and it means that you think about, for example, the effect of multiple embryo transfers.

And you think not just about increasing the chances that your clients are going to have a baby, but you think also about the effects on the children who are going to be born from being one of a number of multitudes once one knows that there are huge health risks associated with multiples.

And we are not telling anybody what to do exactly, but to say enlarge the purview of who you think your patients are when you think about what standard ordinary practice is in this field.

And I think that there is some indication that — and maybe one should say this — that the society by itself increasingly recognizes this, especially if we take what looks like accusatory language out that they would find anything to dissent from here, though that they might be willing indeed to enter more closely into follow- up studies with the pediatricians, because they have an interest in what the effects are of the procedures that they are using on the children who come to be born. 

That, I think, would be the justification for singling this out for special attention.

DR. FOSTER:  Well, okay.  I mean, I understand what you are saying, and you are saying that the primary emphasis of the discipline is to get a baby, and what you want to say is that it is not only to improve the parent's hope of getting a baby, but that what is being produced ought to be done in the safest way, and that is why we are going to try to get the information.

And let's say if you try to take a cell out of a blastocyst, you know, does that mess up something in the future, and that is information that would be there. 

But when you read this, it sort of is like saying to participate with the pediatricians and so forth, and it sort of moves beyond into this discontinuity, and that is what is bothering me.

It seems to me that the emphasis of saying that we need to pay special care to improve our concern for the product of this is really part of what they do, and is implicit in what they do, that we have to try to get that information.

But I don't see how — the only thing that I don't see, it does kind of — you know, when you say should collaborate with pediatricians in making decisions, or obstetricians for that matter that might affect the health and safety of these children.

Well, once the conception is there, then that becomes the business of the obstetrician, and then subsequently — and what I am concerned about is that it looks like their assignment is to act clinically when it is beyond the realm of what they do.

CHAIRMAN KASS:  That is a point well taken.  Absolutely well taken, and we will fix that.  We will try to make this say what we intend and no more, and not to proscribe.  Mike, please.

DR. GAZZANIGA:  Just a sentence on E that I will just mention, and we can sort it out later.  The sentence, "This problem is compounded by the fact that there is not a clear distinction between research and innovative clinical practice in the context of ART."

You can say that in the context of all medicine.  There is always little diddling at the edges and clinicians change the application of the medication, or surgery, and then it becomes a hypothesis, and then it becomes a clinical trial.

And that just goes on, whether you like it or not, and I just think that to — I mean, you may be of the opinion that shouldn't go on in ART, but that is kind of how medicine works, and I just think it sticks out as kind of naive. 

CHAIRMAN KASS:  Mary Ann.

PROF. GLENDON:  I share the concern about accusatory language, but I hope that that concern isn't going to be translated into playing down the fact that after hearing many people on this issue that we have uncovered serious concerns about informed decision-making, and about protection of women and children.  And I hope, too, that in this report concentrating on self- regulation by the profession on the one hand, and legislative regulation potentially on the other hand, or legislative measures I should say on the other hand, that we do not overlook the most important stakeholder if you want to use that word, which is the public. 

One of the things that we have learned is that the public, like ourselves before we got educated on this, is lacking essential information about these procedures.

And one of our charges as a bioethics Council is to raise the level of the public discussion to ensure full public deliberation of these issues, and the public cannot deliberate without information.

So there is yet another stakeholder and another reason for having the best possible information about these procedures. 

CHAIRMAN KASS:  Frank. 

PROF. FUKUYAMA:  Is it okay to make a general comment and not on —

CHAIRMAN KASS:  Please.

PROF. FUKUYAMA:  I think the public as a stakeholder is right, but I again think that the industry itself has really got to think carefully about its own self- interests in this entire area. 

There is this cautionary tale unfolding in another area, which is Mad Cow Disease.  If you look back at the entire European opposition to genetically modified foods, a lot of Americans tend to think that this is all completely irrational, and it has to do with the European protectionism and love of regulation, and so on and so forth.

I think that if you look at historically how this came about, it was as the result of a regulatory failure.  That is to say, that Europeans didn't actually regulate for environmental purposes more heavily than the United States in the 1970s, and they actually regulated more lightly.

There are irrational aspects to the European opposition to biotechnology, but the single thing that drove this entire catastrophe for the agricultural biotech industry there was the regulatory failure, and how the British food safety regulators responded to the initial outbreak of BSE. 

They reassured everybody that it was safe, and the result was that they were proven wrong, and people reacted perfectly rationally to this information about their own regulators. 

And that they had either been captured by the industry, or that they weren't competent to do their job and so forth.  So now you have a lot of consequences, not just heavier regulation of beef throughout Europe, but it has had these spill- over effects to the opposition to genetically modified foods across the board.

And, you know, I have this sinking feeling when you watch the American beef industry respond to the current Mad Cow problem that the beef industry did, and they say, well, we are regulating ourselves, and it should be sufficient, and they are just setting themselves up, and I have no idea how many cases of mad cow disease there are out there right now.

But there is a really big danger that industry, in taking this very light regulatory approach, and so I would think that the big stakeholders, the industry itself, has got to think really carefully about those precedents and its own self- interests.

You don't want to set up a case where a rogue practitioner does something that produces a very disproportionate political backlash.  And all of the big failures in the last few decades have been from industries that were too lightly regulated.

You know, accounting, energy transmission.  I mean, we have seen a lot of cases of this where the industry participants said look, we're taking care of it, and we have our own best interests at heart, and so on and so forth.  And it proved not to be the case.

CHAIRMAN KASS:  Any final comments?  Well, I think we have done very well.  I think we are fairly close.  We see places where the text has to be fixed, and there are some points still in contention about the restoration of a missing paragraph on keeping track of the counts of embryos.

We have conversations to have with at least one of our members, and line editing suggestions can come in when the new document as a whole comes to you, which we hope will be within the next week or two.

And there will be plenty of time for a thorough review.  We will review as we did with the stem cell 3 weeks for review, and we will receive the comments, and you will get the responses to all of your comments, and if all goes well, the target date for this would be the April meeting to be released.

And I don't see any reason given what I have seen why we can't make that deadline.  We are right on time.  At two o'clock this afternoon, we have two invited guests to introduce us to the wonderful field of neuroscience and neuropsychiatry, Robert Michels, and Jonathan Cohen.

I think they will probably both be here in time for the first session, but let's be sure that all of you are.  Two o'clock in this room, and the meeting is adjourned for lunch.

          (Whereupon, at 12:15 p.m., a luncheon recess was taken.)

SESSION 3: NEUROSCIENCE, NEUROPSYCHIATRY AND NEUROETHICS: AN OVERVIEW

CHAIRMAN KASS:  May we get started, please.  This afternoon, we are in for a treat.  The Council is entertaining two sessions on the topic of Neuroscience, Neuropsychiatry, and Neuroethics, taking up for the first time explicitly this particular area of biomedical science, and its possible ethical implications.

Neuroscience, the scientific study of the brain and its activities; neuropsychiatry, the scientifically- based biological approach to healing and relieving disorders and distresses of the psyche.

And neuroethics, and I am not exactly sure that I have this right.  A neologism that is meant to embrace the ethical implications of advances in neuroscience and neuropsychiatry, ranging from the ethical issues connected to technical interventions, such as the use of psychotropic drugs, or deep brain stimulation, to also the implications for human self- understanding on such topics such as the nature of ethical judgment, the character of personal responsibility, the implications for human self- understanding in those areas secondary to the scientific findings of neuroscience.

I don't want to say very much about this.  This is our first venture into this area, though we did touch on some of these matters in the Beyond Therapy Project, where we looked at techniques for affecting memory, mood, and behavior, insofar as they might go beyond the bounds of healing.

But I think it needs a little argument to discover that the studies on the human brain will have powerful things to say about the activities that are central to our humanity and that the human, and ethical, and social implications might very well be profound.

And that since no previous public bioethics body has explored these questions, and we are in a position at least to start thinking about them, we thought that we would invite people to this council meeting to introduce the subject, and to get help, we have chosen two different approaches. 

One, a kind of synoptic overview of this area, and the second a specific area of intense and exciting research interests at the moment.  Before introducing our guests, let's just be clear about our purposes here today.

They are entirely self- educative, and we have no axes to grind.  We are not interested in making recommendations, or regulating, or implying anything wrong about anything that anybody is doing.

We do sense that this is an area of profound importance, and if we are right, we are eager to learn if and how this may be true.  We are very fortunate to have with us today two very distinguished guests. 

First, Robert Michels, who is the Walsh McDermott University Professor of Medicine.  He is also a University Professor of Psychiatry at the Weill Medical College at Cornell University, where he was previously First Chair of Psychiatry, and then Dean of the Medical College.

I have discovered in thinking about this that I have known Bob for almost 35 years when we were early Fellows at the Hastings Center.  He is now on the board there.  Bob was one of the first people in the medical area to recognize the importance of the bioethical issues that were coming, and it is nice to see that unlike me he is still a promising young man.

Our second distinguished guest is Professor Jonathan Cohen, who is a Professor of Psychology, and Director for the Study of Brain, Mind, and Behavior, and the Director of the Program in Neurosciences at Princeton.

And also the Director of the Clinical Cognitive and Neuroscience Lab at the University of Pittsburgh.  He has trained both in medicine and in cognitive psychology, and he is a leader in the study of the emotional brain, mechanisms of decision-making, and moral judgment, and cognitive control, and also in neuro- imaging.

The full- blown curriculum vitae are in your folders, and I won't rehearse them further.  Bob Michels has the task of giving us an overview in the first session, and we will take our break, and then we will hear from Dr. Cohen.  Bob, the floor is yours, and welcome to both of you.  Thank you very much for coming.

DR. MICHELS:  As you can see, I am technologically challenged and here under false pretenses.  Leon said that we have known each other for 30 some odd years, and I looked forward to coming, and with the right audience could probably pass myself off as knowing something about neuroscience, but not around the table with Professor Cohen, and Professor Gazzaniga.

And in the right audience, I could even pass myself as knowing something about neuropsychiatry, but not with Professor McHugh sitting in the audience.  And I guess that must make me a neuroethicist.  I don't know what that means, but since neither of us knows what it means, maybe that's why I am here, and why I have been invited.

I am afraid that in 45 minutes that you will decide that I am not that either.  I am a physician.  I am a psychiatrist. I am a fascinated observer of neuroscience, and neuro- biobehavior research in my own institution, and neighboring institutions, and in the field.

I used to run a very large mental health service delivery system in an academic medical center, and I was Dean of a Medical School, and responsible for the curriculum to educate lots of doctors, and lots of psychiatrists, and at one time the largest psychiatric training program in the country.

And I have been for years an amateur bioethicist.  Those are tangentially appropriate credentials, but they didn't provide me with any real sense of what I might say that would be of value to you. 

So I decided understanding that you are thinking of embarking on a new area, to rather than be educational, to be provocative, with the hope that my provocations might stimulate you to educate each other and have interesting places to go, or things to do afterwards.

My impression is that the explosion of inquiry in these fields lead to new knowledge, mostly knowledge that from the human point of view means greater precision about things that we only vaguely knew before this new knowledge.  I will come back to that.

And to new power, and the ability to do things, mostly meaning greater specificity, the power equivalent of precision, and the ability to do more specific things than we have been able to do before.

That means in general that what we know and what we can do is not qualitatively different than has been true for thousands of years but it may have qualitative significance. 

The quantitative difference may have qualitative significance, because we know in general that the brain is related to behavior, but when we can tell by examining the living functioning brain whether someone's behavior is similar or different than someone else's behavior, we have a kind of precision to that knowledge that makes a difference or that may make a difference from the point of view of its ethical significance.

And it seems to me that it is those kinds of things that you might want to be interested in.  It seems to me that there is an analogy in other areas of science, and medicine, and knowledge. 

It was always knowable what gender a person was usually at birth.  We now can tell close to conception.  That seems to make a difference for certain kinds of thinking and decisions. 

We always found out eventually whether or not someone had the Huntington's gene if they lived long enough, but now we can tell before they are born, and that seems to make a difference, although it is only earlier and more precise knowledge.

We have always known that there is a general risk for all kinds of diseases, somewhere between zero and a hundred for every one of them, but now we have all kinds of ways of finding out very precisely what that risk is for a given individual.

We have always known that there are things about the brain that relate to personality, and intelligence, and the ability to learn, and to make moral judgments, and to reason, and all kinds of things like that, but we have never been able to tell much very precisely about any given individual, and that makes a difference.

We will probably in the relatively early future be able to make much more precise statements very early in life about an individual's probable predispositions to a level of intelligence, or a type of learning capacity, or a type of learning disability, or a style of personality, or a tendency towards impulsive violence, or a capacity for guilty self- reflection, in a way that we have never been able to do before, except by the crude imprecise judgments that we make on psychological grounds.

Those things are not qualitatively different, but they are quantities that may lead to qualitatively different ethical concerns, and it is those that I will try to at least imply in what I am talking about.

We can't read minds, but we are beginning to be able to read brains, and the reading of a brain has implications for what one might be able to find out if one could read a mind, and that ability gives us knowledge with a precision that we have never had, and possible implications. 

I would add, and I feel that I have an obligation to add this from one of my roles, that all this new knowledge and new technology until now for the most part has had much more impact on bioethical discourse that you people all do than on such mundane things as the care of the sick, or health delivery, or things like that.

For the vast majority of people who are sick and go to see a doctor, cutting edge scientific knowledge about their brains doesn't make any difference at all because we have not figured out a system that will allow the knowledge that we had 10 years ago to have a real impact on their experience.

The limiting factors in the experience of sick people in our current system is that the political, economic, and social aspects of the delivery system, not the scientific knowledge of their brains and bodies, and I don't see a lot of suggestion that that is going to be any different in the next decade or two, or three, I'm sorry to say.

As I said, we anticipate new knowledge, and new power or capacity to intervene somehow or other.  Both of these, the new knowledge and the new capacities, can pertain to the species as a whole, or some huge group, like all members of one of the genders, or everybody with some genotype, or phenotype, or can pertain to a given single individual, and they have somewhat different significance.

Let me start with new knowledge about the species as a whole.  We are learning a lot about the neural substrate of the mind; of thinking, of feeling, and even of the things that you do, of ethical discourse, and moral judgment.

We have always known that there is a neural substrate.  There is nothing new in that, and I think nothing particularly important for this group.  However, what we are learning shapes and refines what we think about mental processes, and what we are learning about the brain begins to have impact, and the way that we think about the mind.

And that is important for what you talk about in this room.  There are facts that are not yet known, but are knowable and soon to be known that are relevant to discussions of such issues as who can understand the consequences of an action, or who can decide not to take an action that they are able to contemplate.

Or who can empathize with the experience of another human being, and feel what they feel, or can't empathize with that experience.  Who can change their tendency to behave as a result of experience, and who won't change as a result of that experience.

The facts that neuroscience will teach us won't answer these questions.  They are intensely human questions, but any dialogue concerning these questions would want to be fully informed about, and will be influenced, and will be enriched by those facts, and will be impoverished if it ignores those facts.

I can imagine, for example, that one of the things that you might want to do is think about what would be the appropriate summary of what we know about neuroscience or will know about neuroscience for a non- scientifically knowledge ethicist. 

What difference does it make to an ethicist, or for that matter a Supreme Court Judge what Drs. Gazzaniga or Cohen know about the way the brain makes decisions about when and whether to act, or not to act, and how the individual responds to social responses to those decisions.

For a specific example, I think our longstanding traditional distinction between cognition and emotion is beginning to fall apart, in part because of new knowledge about the brain.

It is going to lead to challenges to the traditional ways that we value these things and we think about them.  Our neurobiology of cognition is older, but it is increasingly accompanied by a neurobiology of emotion.

And, for example, when I read a fascinating recent publication about memory, and the way that we think about memory, and about changing memory of traumatic events, and what difference it might make, it is written as though memory had a single meaning.  As though there was a memory about an event, rather than multiple memories.  It doesn't recognize that there are different kinds of memory.  It doesn't discuss the fact that an intervention might affect one type of memory differently or even oppositely to the way that it affects another type of memory.

It does not discuss the fact that you might, for example, enhance cognitive memory at the same time that you reduce emotional memory, and in fact it might be inevitable that that would be a consequence.

Now, a discussion of the ethics of altering memory is going to be influenced by a more sophisticated concept of memory, which in- turn is going to be influenced by a more sophisticated understanding of the neurobiology of memory. 

I don't mean certainly that a neurobiologist who studies memory would per se be an expert on the ethical issues related, but I am saying that an ethicist who doesn't know what that is about is seriously disabled for optimal ethical discourse.

Once again, I think these matters are going to be of great interest to the people sitting around the table; to bioethicists, to philosophers, and maybe to the small group of people who aren't bioethicists or philosophers like myself, but who love to read the papers that bioethicists and philosophers write, because they are interesting.

I don't think that they are going to be terribly important to physicians, or patients, or sick people, or people trying to make them well, and to what transpires between them unless they first have been processed through a bioethical dialogue, and their relevance is dissected and explained to that group.

New knowledge about individuals, as opposed to about the species, or huge groups of the species in general.  Here I think the kind of impact that this knowledge will have will be different.  I think this knowledge will be far more important to patients and doctors, although it will be a concern of course also to bioethicists.

But primarily a concern to bioethicists because of the practical transactions between patients and doctors that itwill engender, and the ethical aspects of those transactions that will have to be considered.

I can't read your mind, but if I could read your mind, I would have all kinds of moral dilemmas that you would have to help me with.  Reading your brain isn't the same as reading your mind.  But it is a step toward reading your mind.

And if I can tell by devices not yet, but soon, in existence, whether you are feeling guilty or don't when you are talking about something, what it is that triggers your desire, and what is your favorite type of taste, or passion, or perversion, and what the likelihood it is of you being able to control it, or impulsively indulging it, or somewhere between the two, then I have fascinating knowledge about you.

And I have some very interesting decisions to make about what to do with that knowledge and how to use it.  I never worried about those issues, because I can't tell those things at the moment.

But if I could tell, I would begin to worry, and when I worry, you have a job it seems to me to tell me at least how to worry.  In many ways the capacity to acquire new neurobiologic about individuals is analogous to the recently extensively discussed capacity to acquire new genetic knowledge.

But the neurobiology is far more powerful than the genetics.  The genetics tells us about risk factors, and predispositions for diseases or certain traits, but genes only outline the starting gross structure of the system.

A comprehensive neurobiologic assessment of an individual, or perhaps of a fetus, could in theory reveal much more precise information about that organism's potentials, and capacities, and limitations than a genetic analysis could ever reveal.

It would reveal not only the results of the genes, but also the impact of the experiences that occurred to those genes and how they were integrated.  The brain has many complexities that can't be discovered from an even thorough knowledge of the genes that went into designing that specific brain, but could be assessed or described by direct studies of the brain, and we are beginning to become interested in that.

I will take an extraordinarily crude example.  Scientists in my institution, and I believe former colleagues or current colleagues of Dr. Cohen, have been interested in studying disturbances in the acquisition of language in young children.

And they have been able to observe differences in the neurobiology of language acquisition, the sequence of parts of the brain that are involved in acquiring a language that are different than those that will develop dyslexia, as compared to those who won't develop dyslexia.

Now, that is wonderful, and it offers the opportunity for thinking of interventions that will make a difference, and for assessing their ethicacy, but it also opens up some interesting questions about the kinds of things that we might know about a child who has never seen a word because they have seen it, and what that knowledge is going to mean.

Doctors and patients work with phenotypes, not with genotypes, and mental capacities, temperamental flavors, character structure, are all phenotypes, now assessed all the time very imprecisely, very tentatively, and treated rather poorly, predicted poorly, by clinical methods.

But potentially describable, categorizable, quantifiable, and predictable, by currently unavailable, non- invasive, or traumatic, neurobiologic assessments.

For example, imagine evaluating an infant or every infant in order to determine probable future patterns of intelligence, personality, temperament, and the like, and then prescribing child rearing practices, optimal school curricula, optimal environments, metabotropic glutamate receptor interventions, in order to make sure that you steer that child toward, and then we have to think of how to end the sentence.  Toward what? 

We are not quite sure.  We never had the capacity or power, or the need to worry about it, but with the capacity and power, perhaps we should start to think about what it is that we would steer toward, and who we would steer and who we wouldn't, and what are the advantages of intervening or of not intervening.

And what are the implications of a world in which some choose to intervene and others don't?  As in genetic knowledge, the basic issue is the large part of life will be much less unpredictable than it has always been in the past.

It will be more precisely predictable, amenable to greater control.  From the beginning until a few decades ago, we discovered a child's sex at birth, his intelligence in school, and his character, very gradually if ever.

Genetic biology has moved the timetable forward.  Neuroscience will move it much more forward and make the content much more precise.  This opens up questions about the importance of unknowability to being a person, and that is an issue that I think this group would be interested in.

Does it influence our basic humanity if details of our personality and character are knowable at our birth or shortly thereafter, and then themselves shape the interventions which we learn that we will be determinants of those details.

Would we treat someone differently if we knew their proneness to impulsive violence was so great that they were likely to be dangerous to the community rather than creatively innovative in that community, et cetera, et cetera.

New interventions.  Interventions for the species.  Neuroscience and related technologies not only lead to knowledge, they lead to power.  Interventions that affect the species in general, or large groups of the species, seem somewhat science fictiony to me, but I think they are probable. 

We fluoridate water today to deter tooth decay.  Why not add substances that delay Alzheimer disease, or improve memory in general, or even make people feel better, and reduce the incidents of depression, or make everybody just a little bit happier, less anxious, more connected with others.  Maybe that would even make people more moral. 

Are there moral problems in using neurobiologic interventions that will reset the balance between narcissism and empathy, between selfishness and altruism, and by doing that make us a more moral culture?

Would it be moral to make us more moral, or immoral to make us more moral, or moral to leave us immoral.  Very interesting verbal possibilities here.

Is there a difference between raising a child to be a virtuous adult, using rhetoric and persuasion, and language, and reward, and love, and punishment, which all of us have tried at least with our own children, and notice the frequent failures that occur along the way.

Or resorting to a quick, effective strategy that achieves a more effective result, with less trouble and greater certainty, by skipping some of the intervening steps and changing the balance of motivating systems and emotions that control behavior.

Would the result be the same or would the result be inherently different?  New interventions on individuals.  This is where doctors are comfortable.  This is the medical model.  Find out what a person needs, and do something to make them different, and then they will be happier.

And if you are in a good health care system, you will get paid for doing it.  The doctor and other health professionals does something, physical, pharmacologic, psychologic, to the patient, with the intent of curing disease, preventing disease, and enhancing well- being, or even improving function or pleasure.

We are most comfortable with the classic model.  The patient is sick, and the treatment returns the patient to normal, and it ends the sickness.  And the secondary or side effects of the treatment are minor, but they are negative. 

As we deviate from this model, we begin to get progressively more and more nervous.  The patient isn't sick, but only different.  Maybe short, or fat, or fidgets a lot in school, or gets angry very easily, or feels low a lot of the time.

Or maybe even the patient is normal, but like normal people, would like to be different.  They would like to be prettier, or have a more pleasing shape, or texture to skin, or maybe straight teeth, or perhaps deeper insight into his fantasies and unconscious wishes and desires.

Lots of people want those things, although they are not sick.  The intervention has an effect.  It makes the patient more attractive, or stronger, or a better student, but you can't really say that it makes the patient less sick.  It is not even a patient anymore. 

The intervention may also have secondary effects, but the secondary effects tend to be pleasant or desirable, rather than risky, or dangerous.  They may make the person feel good.  The person might even enjoy the treatment.

I have had a longstanding interest in treatments that are so enjoyable that the public has been concerned about making them available because they will bankrupt the system if everyone swoops down in order to get them.  They are so much fun.

People may seek out the treatment because they like it, rather than tolerate the treatment because they need it.  What kinds of problems would this create? 

What does neurobiology promise in this area of personal health care, as opposed to new knowledge, or social, or public health interventions?  Certainly and probably most obviously newer, and newer, and newer, and better, and better, and better pharmacotherapies of various kinds.  The drugs are getting and will continue to get safer, pleasanter, and more precise in their impact.

As we dissect the newer biology of emotion, we will probably have much more precise interventions that influence emotions, that turn off unpleasant ones, and turn on or substitute more pleasant ones.  We will be able to manipulate the balance.

We now have drugs that stimulate and sedate.  We have had those for hundreds of years.  We have drugs that will go a bit of a way towards stabilizing labile moods, and we can counter depression, and we can provide some pleasant highs.

In time, we will be able to tinker with the set point of one's mood or emotional state, elevating one's average mood, but keeping it within the normal range. 

We are playing with strategies for diminishing the emotional intensity of painful memories, and reducing the risk of post- traumatic stress disorder in the process, making the experiences that have always horrified people somewhat less horrifying when they recall them.

Now, some are horrified by the notion of tinkering, with the natural horror associated with horrifying experiences.  Our newfound ability to observe the brain at work will lead to strategies that will enhance the potency of our psychological interventions.

The longstanding problem with psychological interventions has not been that they are not powerful. They are immensely powerful.  It is their almost total lack of specificity, with very little notion of how they work, and what they do, or what their effect would be on a given individual.

We know what the therapists intends to do, but we don't know what happens to the patient very well.  We know what we say, and we don't know what the patient hears, or what it remembers from what it hears, or what he experiences.

And in spite of our patient's fantasies that we know how to do it, we are pretty bad at reading their minds.  But as we learn to read their brains, we get closer.

When we intervene in the body with probes or catheters, or other instruments, x- ray guidance greatly increases our power to do things with those interventions.

Using neurobiologic techniques to be able to observe and measure the effects of our mental interventions will make a similar difference in our capacity or potency to make a difference. 

I would love to know which of my interpretations are heard by my patients, and which ones stimulate their emotions.  Which ones get them thinking.  Which ones cause them pleasure, and which ones make them angry at me, and make them reject me.

And even though in real time, if I had the ability to monitor my interventions the way that my cardiac catheter team can monitor its interventions, I could be more effective regardless of my goal, but that is a scary phrase to add at the end, because I can imagine people that I wouldn't want to be more effective, because I don't like their goals.

Certainly we would all applaud it if was in the treatment of disease, but the kinds of interventions that I am talking about can be used for all kinds of things; selling soap, electing Presidents, treating disease, et cetera.

In a very primitive experiment in my department, the investigators were able to use fMRI studies to determine whether subjects exposed to hypnosis would be influenced in their subsequent behavior, and then confirm our predictions by observing their behavior.  We can tell without talking to the subject whether they have really been hypnotized or they are just pretending to be hypnotized because we can influence their neurobiology by hypnosis in a way they can't do voluntarily.

And that opens up all kinds of interesting potential possibilities.  What about direct interventions in the brain?  We not only give people drugs, but we can stimulate them, and we can ablate parts of their brain.  We can put in tissues from other organisms or individuals, or parts of themselves.

We can use mechanical means to localize delivery of drugs or active chemical agents.  Here my own sense is that the future is extremely far away.  This may reflect my age and phobias in this area, but I think the risks and fears of people tinkering inside of brains so dwarf any anticipated benefits, except for the treatment of devastating diseases, I don't think we will see much in the near future.

Or edging in from the boundaries, and we stimulate the brain by stimulating the vegas nerve in the neck, rather than entering the cranium, or by using transcranial magnetic stimulation without even touching the individual.  So we are getting there from the outside without touching and that is the beginning certainly.

But so far I have seen nothing that makes me think our potency with these manipulations, or their precision is any greater than other methods that we have had before. 

In brief, I think the new knowledge is going to be far more important than the new interventions that we are going to have that are used clinically or in other ways. 

I think they will influence ethical dialogue in general by modifying and enriching our notions of cognitive and other psychologies so that the nature of the mental life that ethicists talk about will be known with the precision that it has never been known before.

Again, the example.  There isn't such a thing as memory without saying that one of the memories, or one of the categories of memory, and we have to start including that into our thinking about what it means to influence memory.

It will pose new problems for biomedical ethics in the traditional sense through our vastly increased knowledge and predictability about individuals' potentials, capacities, and limitations, in terms of personality, behavior, ability to learn, ability to be modified, et cetera.

Interventions that are developed will continue to be more and more specific, and less and less dangerous, and therefore more and more popular for people who desire them rather than only for people who, quote, need them, because they are sick or seriously disabled.

I think that we will be or will need to discuss the implications of using this knowledge and these interventions to give or fulfill individuals' desires without treating disease or disability. 

And we will begin to worry about the differential availability of them and the possible problems of fairness and social advantage, or disadvantage to different segments of society, or different communities that that will create.  Thank you.

(Applause.)

CHAIRMAN KASS:  The floor is open for questions.  Bob, let me start with a couple of things of clarification while my colleagues warm to the task.  You were fairly expansive about our ability to somehow monitor what goes on in the brain, and indeed monitor individuals and screen, but I am just sort of interested in the facts on this. 

Would this require something miniaturizable for — I don't mean for insertion in the brain, but are people going to walk around with imaging devices so that one can check up?  I mean, how is this going to work?

And the second question related to it is that I am also interested not just in the technical ease of this kind of monitoring, but also what you call the predictive value of the information.  Why would certain kinds of screening early on be anything more than, let's say, probablistic?

Could you say something about how good is the prediction, and how are we going to get this kind of massive amount of information about all of these mental things through checking up on brains?

DR. MICHELS:  Let me start with the second, because I might be able to answer it.  Of course it is probablistic.  But there is a difference between our current imprecision of such prediction, and highly precise predictions. 

What if we could after an MRI of a 6- month- old tell you what the range of the future IQ was going to be as fairly reliably predicted from the ratios of various brain measurements?

Certainly if you could identify future geniuses, you would want to exploit that potential, or somebody would, by early schooling.  And if you could identify those who are never going to learn very much, you would want to conserve resources in order to have them available for the first group, et cetera, et cetera, et cetera, or some would argue this.

That is impossible without the technology that allows still probablistic, but more precise than current predictions.  I would say that the chances of the probabilities becoming socially relevant early are for the first time in the history of the species real because of this.

The predictions until now have been made on the basis of correlations with heavily disputed characteristics that are not just to correlate with, like family, class, race, social background, et cetera.

But what if we had real correlations with the biologic potential?  Where do we go from there?  I think that the probabilities will become socially relevant within the foreseeable future. 

Your second question, or your first question — I'm sorry.

CHAIRMAN KASS:  My other question has to do with how we are going to get all this relevant information, this information.

DR. MICHELS:  I raised two different types of situations, but what I am talking about now in theory could be MRI scans with enough precision and enough knowledge about the importance of the various variables that could be done just as we now take core blood from every child born in the New York State to measure certain genetic predispositions to disease.

CHAIRMAN KASS:  Done once?

DR. MICHELS:  Possibly, or maybe done twice, or maybe done five times, or maybe tests that would be challenge tests.  So maybe under observation we would stimulate the infant and see how the brain responded to that stimulation.

But they are foreseeable doable within the range of economic and social possibility.  It might take 20 minutes in the machine, and five stimuli in watching the brain's response to it to get a sense of a pattern that we would note from studies correlated with this probability of future outcome.

CHAIRMAN KASS:  Dr. Cohen, would you like to just join on this?

DR. COHEN:  Yes.  I pretty much concur with everything that Dr. Michel said, but I would add maybe to just the force of his comments the fact that there are technologies that at the moment compliment, but at least in the foreseeable future might begin to replace MRI in certain settings that are much more portable.

Optical imaging, where you actually shine light into the skull and measure the refraction characteristics or the frequency spectral characteristics of the return light to provide another way of measuring blood flow, which is effectively what most forms of functional MRI are measuring now.

And there are attempts to develop extremely portable versions of this. There is a guy at the University of Pennsylvania who has developed what he calls I think — and I think somewhat glibly the Cognitron, which is — I think it is a couple of gram device that you can affix multiple ones of on the scalp, and he has a picture that he shows when he talks, and he says this is Britten Chance of a classroom of Japanese students where he has done a study with this thing in a math class.

And 10 of these devices on each of their heads.  Now, right now the information that that device is giving us is rather imprecise and nowhere close to the kind of information that Dr. Michels is describing.  But I would conjecture that it is at most a matter of time before it comes close.

CHAIRMAN KASS:  Thank you.

DR. COHEN:  With MRI, we are much, much closer to that sort of precision and non- probablistic sort of information.  Studies are getting done now on choice preference behavior that are close to being able to reveal meaningful information about individuals from a single scanned section.

And with regard to what their preference is for, say, Coke versus Pepsi in a double- blind study, where you can look at the brain and figure out what they are going to prefer.  So in some domains I think it is getting remarkably close to the sort of scenario that was described.

CHAIRMAN KASS:  Thank you.  Dan Foster.

DR. FOSTER:  You know, let me just follow up on that, because if you look at the experience from laboratory science, let's say, in molecular biology and so forth, the more we go, the more it gets more complicated.

You know, you used to have a gene, and a messenger RNA, and one protein, and that used to be the dogma; one, one, one, you know.  We now know that is multiplied in dozens of ways.  I mean, you splice the messenger RNA differently, you know, and then you put on different carbohydrates and so forth, and it is much more complicated.

It seems to me that you are talking about events, even with what you just said with shining light in, in the most, I suppose the most complicated organ that we have in the body.  I would find it very difficult to determine what a specific — let me just be crude. 

You light up a PET scan, and you are looking at glucose metabolism, or blood flow, or whatever, which are really when you look at it pretty crude compared to what the neuronal networks and interactions, and if you watch these things grow when you are growing them as the biological people in the brain are doing, it is hard for me to sit here and believe that you are in a meaningful sense going to be able to predict whether — you know, whether somebody's whole neurobiological life — maybe that is right.

But I can't believe that this most sophisticated organ is going to be easier to understand than less sophisticated, but very — you know, things along this line. 

I hope — I don't know if I hope that it is true or not, but it seems to me that there is a huge jump from what we have got right now with functional MRI, and I think you can — and I am sure that you are going to talk about this.

You can tell what — you know, give a thought game, and making a moral decision, and see what part of the brain lights up or something.  But the sort of things that you were talking about Dr. Michels, it seems to me that they are going to be very difficult, because almost always their final common pathways are in memory.

I mean, hearing gives you something different, and you end up in the same place, but writing, or verbal, or visual, how would you — I mean, why are you — I guess what I am saying is why are you — you started off by saying that you don't want to hide things.

But why are you so certain as you seem to be that we are going to be able to do that?  I am just interested.  I am not arguing, but I am just interested.

DR. MICHELS:  As I said, I tend to be provocative.  I am pleased that I have at least in one case succeeded.  I am not certain, but I think this.  The brain is a black box, and it has been a black box forever. 

It is only within the last decade or two that we figured out how to look inside the black box in life, in humans, and we have found that we have knowledge in that box that correlates with socially discernible important variables, an entirely new area.

We have never had this available to us before, and our techniques are growing in potency by leaps and bounds.  I think it is unimaginable that we won't have relevant knowledge that increases significantly the precision of the predictions we have long made on psychological and social grounds.

Those predictions are so important about human life that anything that increases the precision of them is ethically relevant.  My guess is that those increases are moving so fast that they are going to be relevant to every day social decisions about what class to put a kid in, about whether we are — and we are almost at the point now where we can give meaningful advice about what technique to use to teach a dyslexic child based on information that we obtain without talking to the child.

Now, that is pretty startling to me, and not terribly far from deciding whether a kid is going through an adolescent crisis, or is a future probable, highly probable, violent criminal.  Those are morally relevant decisions, and morally significant information about them that we have to decide how to cope with.

And I don't think that those kinds of things are terribly far away.  Again, I back away.  We have experts in the room that can comment.  I am glad you came out on my side on this one. 

CHAIRMAN KASS:  I have Michael Sandel, and then Alfonso. I have got a queue and I think I have noticed everybody that wants in.  Michael, please.

PROF. SANDEL:  Well, this is just two questions of clarification for Professor Cohen.  The functional MRI is an MRI whose purpose is to determine what parts of the brain are functioning when certain experiences — and that scenario with the Japanese school kids in the math class with scanning devices on their brains, that was to determine how they learn the math, or it was to teach them the math?

DR. COHEN:  It was definitely measurement and not intervention. It was an attempt to see in that case the frontal lobes, which were more activated in one case than in another.  A very, very crude study.

I don't want to overdramatize the findings, nor the method, other than to say it answers the question that was asked, which is how portable can we imagine these methods being, and the answer is possibly very portable.

PROF. SANDEL:  If the knowledge of the function of the brain became precise enough could we use such devices to teach the math as well in principle do you think?

DR. COHEN:  Well, no, because these are measurement devices, and they are not producing any signal that influences the brain, but Dr. Michels did refer to one method, transcranial magnetic stimulation, TMS, which is also in principal a very portable device, that can influence the brain, and is in fact already beginning to see some clinical applications.

So it is being used, for example, as a potential alternative.  It is being explored I should say as a potential alternative to electroconvulsive shock therapy.

Where in effect you produce a localized seizure that carries with it possibly much less memory loss and lesser risks than those that are associated with generalized seizures.  So that method is in fact already seeing clinical use, and is also beginning to see perhaps even more extensive use in basic research.  I will say more about that later if people are interested.

DR. MICHELS:  A footnote to Dr. Cohen's comment.  I think it would be immensely — have immense impact on teaching if you could tell by methods such as this when the students have learned what you were teaching them.

If you could tell when the brain pattern shifted, because they got it, and then they were processing it differently than they were before, as an educator, I would find that very, very much powerful in shaping my intervention. 

DR. COHEN:  Can I have a quick response to Dr. Foster's comments before we move on to another question?

CHAIRMAN KASS:  Please.

DR. COHEN:  Actually, nobody is more sympathetic to the concern in the question that you raised than myself.  I mean, it is my view that neuroscience as a whole has missed the boat on the complexity of the brain, and there are many consequences to that realization that neuroscience has not taken on that I think are absolutely essential, and I will say a word about that in my talk.

You know, appreciating the anomaly of dynamics, and the need for formal theory in a way that we see in every other discipline that confronts such complexity.  So you get on and saying that these methods are not going to unravel the whole thing in the next 5 or 10 years. 

That said, there is no predicting as a scientist or from any other perspective what is going — what knowledge is going to yield the simple description, and what knowledge is going to require more deeper and more complex understanding.

And in every other domain of science some very powerful things have come from some rather simple insights, and then others have required much more sophisticated theories. 

So the extent to which I agree with Dr. Michels is in saying that as we suddenly gain new methods that we didn't have before, and are able to peer inside a box that we couldn't peer inside of before, some things are going to lend themselves very quickly to discovery, and perhaps to simple accounts, and to simple correlations that will have great impact.

Others, perhaps most, no doubt will require much, much deeper understanding, and much longer research programs.  But just as in genetics, you know, knowing the entire code doesn't tell us very much about the makeup of the person in all the rich ways that we think are relevant to their day to day function.

Nevertheless, it allows us to predict some very important things, like whether or not they are going to have Tay Sachs disease, or whether they are going to have Huntington's chorea, or a whole host of other things that have immediate medical impact. 

And I think the scenario is going to be the same in neuroscience.  There is going to be a host of things that are going to be upon us before we knew what hit us that we can predict, and then a whole lot more that is going to take a lot longer to understand.

DR. FOSTER:  Thank you very much.  I would say that I have a sentence that I always say, that I never say never, and I never say all ways in medicine or science.  So, I am not saying never.  I am just making a comment.  Thank you very much for your clarification.

CHAIRMAN KASS:  The queue has now grown, and so let me ask people to be fairly succinct so we can get everybody's questions.

PROF. SANDEL:  You could scan them to see how long their question is going to be before you call on them.

CHAIRMAN KASS:  Actually, I have a simpler method.   Alfonso, please. 

DR. GÓMEZ-LOBO:  I am going to go back to the little Japanese boys, the mathematicians, because I am expressing a perplexity here, and it has to do with the following.  From your explanation, of course, these devices would be measurement devices of the brain activity while engaging in methodical thought.

But of course that will not tell us which of the answers they provide to certain equations which are true and which are false, first of all.  In other words, there is this problem with the mind that we want to know the truth, and from what I hear here, the truth about mathematics, about a mathematical statement, is certainly not going to come from the brain, right?  Okay.  Let me try another one. 

PROF. SANDEL:  Can you say that again with your microphone on?

DR. COHEN:  I don't know.  I mean, I am not entirely sure what you are asking. 

DR. GÓMEZ-LOBO:  Well, that's wonderful, because then I am going to get more time to make my point.  Let me make it in a slightly different form now with Dr. Michels. 

I thought that your description of examining the six months old children to determine whether they were going to be alpha, beta, or gamma children — I mean, I am parodying you know what.

No, it is not the brave new world.  I am parodying Plato's Republic.  You know, you take a look at the children that are born, and if there is gold there, fine, and they go to the upper class, and if there is silver, they go to the gardens, and if there is copper, they go to the merchants, et cetera.

But the problem then would be, well, would this be just, would this be fair, and nothing I think it seems in the brain is going to tell us whether this is just or fair.

In other words the question about the truth of the judgment made on the fairness of that distribution is to be found in another domain.  In the case of math, it is certainly the actual system that determines the truth of a claim of mathematics. 

I just cannot fathom say decidability theorems that Goedel decided by scanners.

DR. COHEN:  Well, it is interesting that you picked Goedel, because Goedel was among the mathematicians that pointed out what the limitations of any particular proof system can prove, and it may be that the most profound impact that the eventual understanding that we have of how the brain works will be on understanding what the actual fabric of our conceptual systems are, and what constrains them.

And although at the moment I don't think we are anywhere close to being able to look to the brain to develop prescriptive principles of ethics or knowledge in general, it is not inconceivable to me that ultimately as we understand how the brain works that we will gain new insights into the very basic or the very bases of what knowledge is.

And I will actually — and that is in part the main focus of the talk that I will give. 

DR. GÓMEZ-LOBO:  All right.  I will wait until you give your talk now.

DR. MICHELS:  Just a very quick response.  Certainly we are not going to know whether it is good or bad to do this based on studying the brain.  The brain doesn't tell us that, but we have never before have been able to make precise predictions very early about what the child's individual capacities are in many areas where those predictions will become available.

We then have not a strategy to use, but an interesting dilemma of what to do with that potential knowledge; discard it, exploit it, expunge it, reveal it.  Those are the things that I think this group is interested in.

CHAIRMAN KASS:  Frank Fukuyama. 

PROF. FUKUYAMA:  Well, thank you.  That was really fascinating.  I just want to ask a factual question that was not clear from your presentation.  You have the brain's genotype, and then you have its phenotype, but then beyond that, it seems to me that you have the actual — you know, what is actually contained in the phenotype, which in an analogy would be software in a computer.

The same hardware can contain different programs towards memory and so forth.  Now, it is not clear to me from what you have said which of those three things are measurable by these external devices.

I can certainly see that you could see something about the genotype, and I presume when you are talking about predicting the capabilities of a developing child that you are looking at the phenotype, and how that might develop in the future based on certain physical characteristics of the brain.

But how much are you saying that you can actually measure things in that third category which have to do with what actually fills the content of a given phenotype?

DR. MICHELS:  I don't think that those categories are adequate for the brain.  The genotype, the genes, present constraints or limits on the structure of the brain.  Much of the structure though is not determined genetically, but is a function of various post- genetic determination because of various environmental conditions or whatever, and experience.

And of course the content is heavily shaped by experience.  The techniques that we are talking about measure the sum of all three.  The content is really part of the phenotype, and the content influences the structure of the brain.

So one's experiences influence the relative size of one's hippocampus and one's amygdala, and the balance between them, and those in turn shape future experience.

PROF. FUKUYAMA:  Okay.  Could I just modify that then.  Does the content actually have to result in a physical modification of the brain for you to be able to measure it, or is there a way of getting at the content directly without — in a case where there is no physical difference?

DR. MICHELS:  To a contemporary neuroscientist, it is impossible for there to be content without some physical modification.  It may be at the molecular level, and it may be at the semantic level, but what does it mean to say that the content is different, but the brains are physically identical?  That would discard science, and speak to some type of spiritual notion.

Every thought is connected with some structural, or functional, or chemical difference in the brain. 

CHAIRMAN KASS:  And I assume that somebody that disagreed with that is simply — has a different structure of his brain?

DR. MICHELS:  I would say momentarily until I talked to him.

CHAIRMAN KASS:  Okay.  Then the question of truth becomes somewhat — it is, I think, what Alfonso was getting at earlier, but let me not intervene.  Mary Ann.  I have got a long list, but let's try to get through everybody before the break.  Mary Ann Glendon, and then Bill Hurlbut.

PROF. GLENDON:  As a non- scientist, I have been debating with myself whether I should even enter this conversation, but it was so interesting.  Your question of what would a society be like if these probabilities became socially relevant. 

And it occurred to me maybe we know a little bit about that already.  I would start with what social scientists know, that in the 1990s, until the 1990s, more than half of the inhabitants of the world lived in small farming or fishing villages of fewer than 2,000 people.

I might be more the only person in this room that grew up in one of those kinds of villages, but there is an intense interest in heredity among farmers, and they just don't apply it to animals.

And when you live in a society that is not very mobile geographically you have a little laboratory, where you see generations and generations.  And I think we already know a little bit about — I mean, certainly they have a lively sense of heredity and probability, but they know that it is just a probability business, and they also have a lively sense of variations, and things that aren't determined.

So what you know is that there are some characteristic advantages and disadvantages, and the disadvantages are the ones that make a lot of us move out of small villages.  You tend to get families — whole families tend to get typecast, and there is — well, I don't have to go into it.

But on the other hand, there is also this sense — you posed the question how would we know what is good about this.  There is this sense of maximizing the opportunities for people to perfect their own gifts, whatever they are.  That would be the other side of the coin.

So I was just wondering if maybe in our highly mobile societies where we have lost that kind of little experimental knowledge that maybe at least in the near term fancy science will get us to the point that agricultural societies that were not very mobile had already been.

CHAIRMAN KASS:  Let me continue down the row.  I have Bill Hurlbut, Gil, Paul, Bill May, and Mike Gazzaniga, and then we will break then.  Anybody who wants to speak after that, we will do it in the next session.  Bill. 

DR HURLBUT:  I wanted to jump back upstream on our conversation a little to Daniel's comment.  I wholly concur with the concern that we not fall into neurologic reductionism and simplistic notions of how things work at the level of behavior.

(Inaudible) seemed to me to be very important because the information as Dr. Cohen has mentioned, the certain things that might correlate, are actually beginning to emerge in the evidence. 

If it is true that there is a long journey between genotype and phenotype, and if you think of the genotype as fundamentally expressing the genes, which are then greatly modified and they kind of play out in these complex patterns interacting with one another, and you think of those as pigments, and you think of the phenotype maybe as the picture that finally is expressed with the pigments of the paints, still what we are doing here now as Dr. Michels has mentioned is that we are further upstream in that process of the patterning out of the person.

And the point is that now we are not looking at something as primordial as the genes.  We are looking at something just a layer or two before expressed behavior.  And there are in fact already at least six papers which now correlate fMRI patterns with the expression of single allelic differences.

There are papers associated with brain derived neurotrophic factors, and better memory, serotonin transporters, anxiety, stress, proclivities toward depression in some genotypes; amygdala and anxiety correlations, and correlations between phenotypic expressions of pain, and of course neuro or dopamine transporters, and some of the work that Dr. Cohen has done between dopamine receptors and phenotype.

These seem to me to be highly relevant in their ethical implications, and so that I just don't end up making a statement, I want to ask you a question.  Do you think that we will get to the point where we will discern these transitions in learning that you mentioned, and also discern the very pharmacologic intervention that provokes them, and get to the point where education is no longer just kids sitting in desks, and trying to concentrate, but actually neuro- enhanced sessions, maybe with short- acting psychotropics; that now it is time for your math drug, and now it is time for your literature drug?

DR. MICHELS:  That sounds scary, but I think the answer is basically yes.  I don't think that it will happen that way.  I think what will happen is the 6- month- old will be scanned and evaluated, and we will find that this is a nice, sweet, wonderful  6- month- old.

You see, that little gyrus there is a little bit twisted, and the balance of neurotransmitters is a little atypical, and kids like that have trouble with spacial learning link.  He will need a boost when he gets to calculus. 

So instead of giving him a drug for learning disability for years, which he doesn't need, or giving him nothing and dooming him to a lacuna in his final capacities, we will know that in that week of lessons a little bit of a push might have minimal side effects and will help him through what his brain is limited for, and he will be happier as a result.  I think that is foreseeable.

CHAIRMAN KASS:  Gil Meilaender, and then Paul.

PROF. MEILAENDER:  I would just like to think with you a little bit about this.  I am not quite sure where or what I am about to think about these, but you had said that the notion that we might have two brains exactly different, or exactly the same, but the choice was different, was sort of inconceivable. 

If you had the two brains, the thing would have to come out, and I found that I don't find that inconceivable at all, but of course I am not a neuroscientist. 

You said what would that mean, and the answer is freedom, and that is what I want to think about a little bit.  What I want to know is whether there is any place in here for chance, or willfulness.

There are fascinating things in Augustine's City of God, where he is thinking about free will, and he talks about the astrologers, and he wants to argue against astrology, and about how he finally uses these examples about how the son of the master and the son of the slave were born under precisely the same astrological signs, but turned out entirely differently.  I am just wondering if there is anything analogous to that in this area, and obviously in much more sophisticated ways.

But if you can tell something about my brain, that I always choose Coke rather than Pepsi, what does always mean?  Is there room for chance, or is there room for willfulness, where I just don't want you to know about that?

And if this doesn't make any sense, then what do we say about freedom?

DR. MICHELS:  A huge question obviously.  First, I would not lump chance and willfulness.  To me, they are opposite.  Willfulness is —

PROF. MEILAENDER:  There are many different ways of breaking the pattern is all that I had in mind.

DR. MICHELS:  But willfulness implies determinism.  It means —

PROF. MEILAENDER:  No, I was thinking of willfulness as something that stands outside the whole system of causes.  It means free will.

DR. MICHELS:  Well, clearly —

CHAIRMAN KASS:  Dostoevsky's Notes From the Underground maybe.

DR. MICHELS:  To a neuroscientist, I think the notion of chance or something outside of the causal system doesn't mean anything.  It does not fit the language and discourse that that community is involved in.

PROF. MEILAENDER:  Is that a scientific point or a philosophical one?

DR. MICHELS:  It is clearly philosophic.  That is not the result of a science.  That is an organizing frame within which the scientist formulates and addresses questions as I understand scientists.  We have a couple in the room. 

CHAIRMAN KASS:  I think his brain is wired differently.

DR. COHEN:  Well, I think on that point that I would take a slightly different stand, and I would distinguish between free will and chance.  I would say within all of science that there is the notion of chance.  I mean, right down to the quantum mechanical level. 

I mean, that is built on the notion of chance, that there is indeterminacy in the physical world is the essential notion in modern physics.  And I think the same is absolutely going to apply at the level of neuroscience, and so is there an opportunity for what we technically call symmetry breaking?

You have two identical brains confronted with slightly different environments, and they may go the same way and they may not.  So, absolutely it is an essential notion, and in fact we formalize it in many of our mathematical models as noise, and it turns out that has important properties well beyond the scope of this discussion.

But just to say that not only is it possible, but it is embraced theoretically in an extremely important concept that there be chance, or randomness, or noise, in the operation of the nervous system.  That is distinct from the notion of free will, where that will comes from some material or plasma that is outside of the physical or material realm.

And there I agree with Dr. Michels.  I say that as a neuroscientist, and not speaking as a metaphysician, or a philosopher, but as a neuroscientist.  It makes no sense for me to talk about any things outside of that realm.

I am willing to be agnostic as to whether or not there is ectoplasm that exists outside of the material world, or some force of nature, or God, or whatever you want to call it, that has influence.

But as a scientist that is not the game that we play.  The game we play is what can we explain in terms of physical cause and material existence.  And from that perspective as a neuroscientist, I don't think it makes much sense to talk about influences that exist outside of the material world, and with regard to neuroscience, the relevant material is the brain.

PROF. MEILAENDER:  Just a sentence?  Your agnosticism though then would have to mean that it might be possible that your predictions could be falsified by something that is outside of the realm that you are working in?

DR. MICHELS:  I think this is going to take us longer to work out than we have, but if you are asking for falsification in a material form, the answer is no.  That is the game of science. 

You give me material evidence and that is perfectly good, and I am going to say it always has to be material evidence and so we are back to the scientific game. 

DR. FOSTER:  But just one sentence then.  You have already talked about the quantum mechanics and everything.  The uncertainty principles apply everywhere.  So in one sense, you can't — it is too much to talk about right now.

But there is inevitably with, whether it is a photon through the Schroedinger's Cat experience and so forth.

CHAIRMAN KASS:  My electrode says that Paul McHugh wants to speak. 

DR. MCHUGH:  Thank you very much, Bob, for that interesting fairy tale.  I have been listening to this fairy tale for so long.  Look, first of all, we are already now working with our understandings of potential, and organizing the environment of children, and probably maybe with some further knowledge of brain structure, we can do it a few years earlier than we do.

As you know in the public school systems of New York City right now, children at age 6 are selected to go to Hunter Grammer School out of the basis of their scores on psychological tests and it works out pretty well. 

The predictions are extremely well, and we are doing it right now, and if you could do it at age four rather than at age six, that might be an advance.  But knowing the gelatinous layer or gelatinous appearance of a six month old brain, having looked at a lot of them, I am quite sure that there are limits to what you are on about.

And it was that that brings me to my question.  You say appropriately that we are going to get more precise, and I want to know where the limits come given that at the moment none of the neuroscientists can tell us anything about how consciousness emerges from this material. 

If you can't tell us how consciousness emerges from this material at all, you can't tell us what makes us see red when we see red.  How do you really think that you are going to do all the things that you tell us you are going to do before you can answer that question? 

I acknowledge what Dr. Cohen says, that there are going to be surprisingly simple things that are going to emerge from this, but that is not the picture that you are depicting for us for our ethical concerns.

You are depicting for us a sense in which we are all powerful and are capable of doing things that this neuroscience is going to do it.  Do you think that there are limits to what you can achieve given that I don't see in the next hundred years that you are going to solve the brain mind problem. 

CHAIRMAN KASS:  As long as you would like.

DR. MICHELS:  A point of personal privilege.  I am delighted that Paul considers me a spinner of fairy tales.  I couldn't imagine a higher status to achieve in the world or in his eyes.

He is conflating the two categories that I talked about.  One is the implications of our new knowledge for our understanding of the species of cognitive psychology, and then indirectly of moral discourse.

I don't know how consciousness emerges from this gelatinous mass, but I do know that it wouldn't be very helpful to me sitting with a patient, or with my 6- month- old granddaughter, to know the answer to that question.

It might be helpful to me to know whether next year I should enroll her for ballet lessons or for learning how to play the violin, or maybe for ice skating.  That would be useful information. 

And I think that is the kind of information that we are going to get from studies of individuals.  We are not going to progress the way consciousness emerges. 

Before that, we are going to learn that memory is complex concept, and that emotional and cognitive records aren't filed in the same cabinet, and that might get us to rethink some of our notions  about the nature of man.

But again that isn't what is going to influence the way that I make decisions about my granddaughter's education, or assign kids to school.  I agree thoroughly with what Paul said.  We make these predictions all the time based on strategies that we have used for a hundred- thousand years.

Within the last 20 years, for the first time, we have an entirely new class of data never before available to us which promises much more precise and specific knowledge on which to make therefore more precise predictions.

They will still be probablistic, and they will still be predictions, but that is a quantal leap that may have qualitative significance in terms of its social implications. 

Partly because that information will be available to some groups and not others; partly because it will raise questions of resource distribution and fairness; partly because it will raise questions of whether or not we want to make decisions based on such information, or only use our traditional sources of information because they are "more natural."

All of those are not new ethical issues.  But this area will make them have a different concrete significance.  I think that Paul is agreeing with that, and so I think it is a very important fairy tale that we would suffer if we ignored.

DR. MCHUGH:  I agree with you up to a point.  The issue that I am trying to raise with you is the issue that Gil is talking about, too.  That is, that we are people of body- mind continuum, and the issue of developing and recognizing that the brain is important, and that particular parts of the brain are important, and particular parts of the brain are in action when we have a thought, and this work is very interesting, and I would agree very important up to a point.

I am concerned that it is being over- hyped, and we are getting so far from what in our promise for what we would deliver that we are trying to scare people  about what our limits are, and all I am saying is that for me, that if you can't tell me how the brain produces this conscious experience at all, and then let me remind everybody that we can't do it at all.

And yet you think that we are going to be in a process of a kind where people would likely to be in a situation where we are putting stuff in the drinking water and reproducing Walker Percy's example in Love in the Ruins.  I just think that is a fairy tale.

CHAIRMAN KASS:  Bill May and Mike Gazzaniga, and we will take a break.

DR. MAY:  You seem to be claiming that there are proffering a fairy tale, but scaring people with a nightmare.  So far we have talked about the potentiality of this with medical interventions, and then we got into the discussion of education.

But I couldn't help but think about this potential for personal relationships.  I mean, there is nothing more daunting for a young man to declare his love, and it exposes him to extreme vulnerability, potential humiliation, and awkwardness and so forth.

But if I could get a hold of her black box, then think what that would do, and embolding me in overtures, and of course from her side, there might be the feeling that transparency is not all that good a thing, and one would retreat to the ancient wisdom women have of the importance of veiling, and the importance of that in human affairs.  It is a frivolous comment, but it comes towards the end of this session.

CHAIRMAN KASS:  This is an argument for ignorance or for a certain kind of ignorance.

DR. MICHELS:  A quick one- liner, Leon.  In the Hasidic community in New York City, you don't go out on a date without first checking the genome of your potential partner for recessive genes that might cause trouble.

It probably will be at least 5 or 6 years before they will add an MRI to the genome before that date. 

CHAIRMAN KASS:  Looking for what, rabbis?

DR. MICHELS:  For fittedness that will survive, rather than lead to conflict that will disrupt the family.

CHAIRMAN KASS:  Mike Gazzaniga.  He is going to clear this up.

DR. GAZZANIGA:  Welcome to neuroscience everybody.  So, Bob, your talk takes me back to Cornell and many grand rounds and so forth, and I can of hear a couple of things from your talks.  You have always had sort of a love- hate relationship with science.

So let me see if I have this right, and you correct me if I am wrong, because I think you can offer us a possible insight here.  As I remember, you came out of the psychoanalytic tradition, but you were every scientifically fascinated, and you learned, and you loved to talk about it.

And then you studied for years people who were severely mentally disordered, and schizophrenia, Tourette's and a bunch of diseases, and with manic- depressives, and let's take one for example, schizophrenia, and along comes dopaminergic hypothesis, or it clears up what the hell is going on here.

And there is a solid biopsychiatry brainstorm.  And people take the appropriate drugs, and they feel better, and they behave better, and so forth, but nowhere in there was there any understanding of why they thought they were the King of Siam, you know?

I mean, the person was sick, this dopaminergic problem or whatever which one, a neurotransmitter problem or whatever.  Yes, it fixes the brain, but it doesn't explain why we have been dealing with this patient for years.

Now, that revolution sort of puts psychoanalysis on the junk heap of ideas for most of us, and you lived through that.  And I am trying to get at why — I hear that you are fascinated with neuroscience, but you are also quite clear that it has severe limitations on what it can explain, because you know this fact.

You know that neuropsychiatry didn't answer or ever answer that question.  They just moved on.  They didn't know why these people had all these crazy thoughts.  They can just fix their brain chemistry.

Now having lived through that, and having had to rethink — I assume you had to rethink all those things in your mind, can you apply the principles that you learned from that to what this problem is about our increasing knowledge of neuroscience, and what it may mean for normal human cognition?  Does that make any sense to you, that question?

DR. MICHELS:  I am not sure, Mike.  I am today a practicing psychoanalyst.  I never left that.  I was a scientist, a laboratory scientist, before that, and not after that, and so I am not exactly in the history that you outlined.

But I certainly have had a life- long interest in both.  I have no doubt that there will be unanswered questions at any point along the way, and I have no doubt that our traditional fascination with symbols, and meaning, and extra personal socially determined communication is part of our notion of being.

And all that is important in making one human isn't within your brain or your skin, because it has to do with things like language that certainly can't be understood within a single nervous system.

But I think — my view is that the neuroscientific explosion of the last few decades has opened a black box.  We only have glimpses in the box, but we never were able to open it before, and that new knowledge is trivial compared to what is unknown, but immense to what was known, and it is going to make some differences.

CHAIRMAN KASS:  Before the break, might I just clarify one point, Bob.  I take it that you think — rather than think about the actual interventions, you think that the most important first set of topics that we should be thinking about are the implications of a new kind of probablistic, but nonetheless predictive, and more specifically predictive knowledge for thinking about the future, especially of children?  Would that be a fair —

DR. MICHELS:  No, I will go back.  I divided my thought into four parts.  I think the first thing that I would be interested in is the implications of this new knowledge for your view of man.  The lessons of modern cognitive psychology for your discussions of moral psychology.

The second part would be the implications of knowledge about individuals, analogous to genetic knowledge, but far more important and further — and I forget if it is downstream or upstream, but further or closer to the output that we are clinically interested in.

I think interventions are much further down the pike and much less important, and much weaker, and probably in general will be starting as most interventions do, well within the current medical model, and I think that many of the issues of intervention you have already discussed, and they are not new ethical issues, because the intervention happens to be above the neck rather than below the neck.

CHAIRMAN KASS:  Thank you very much.  I thank you all.  We will take 15 minutes, and we will look forward to Dr. Cohen's presentation.

(Whereupon, at 3:33 p.m., the meeting was recessed, and resumed at 3:54 p.m.)

SESSION 4: NEUROSCIENCE AND NEUROETHICS: REWARD AND DECISION

CHAIRMAN KASS:  Let's proceed, if we might.  I'm in a different spot so I can see the PowerPoint presentation as well. 

Dr. Cohen, would you just simply begin, and we look forward very much to what you have to say.

Mary Ann, why don't you take a seat over here so that you can see the presentation.  Thank you.

DR. COHEN:  More importantly, so I don't shine the laser pointer in your eyes.

So thank you very much for inviting me.  It's quite a privilege to be here.  I have to say, the strongest impression I have so far is how cordial the proceedings are.  One from the outside imagines that debates about such hot topics are intense and vituperative, and they're just intense which I found really enjoyable so far.  And I hope it continues that way.

So I was kind of — I was mandated to do something slightly different than Dr. Michels did which is to give you kind of a case in point.  And I struggled long and hard over what case I should give, in point, because I think there are many that actually are not the obvious ones to discuss, but that nevertheless you should be aware of.

And what I decided was to stick with the one that struck me first I should do, largely because it's the most accessible one.  And it certainly — I was kind of reaffirmed in our discussion in the last hour that that was so because many of the topics and issues that I hope to address have already come up.  But what I want to do, just to guard against provincialism as best I can, is to just put up a couple of issues that I think are really important, maybe some cases — and I have this one here starred because I think it's maybe more important — that over the course of this discussion; that is, your discussion over the next whatever, months, years, you will be attentive to because they will give you the eye on the long picture and not just the short one.

And maybe the most important one is the fact that what is really lacking in neuroscience, which is a theoretical framework, is just starting to show the seeds of development, at least within the domain of understanding high level human behaviors.  It seems inconceivable that we could ever really, as people have expressed already today, that we could ever really come up with an understanding as something as complex as the brain in a way that will tell us how people will behave, but I would submit that there are just the beginnings of that in the theoretical world, and there are a couple of developments that I highlight here. 

One is the diffusion model, and it's something that would take an hour to describe to you but I think is easily understood when it's properly presented, that is an instance of where we're really gaining an understanding in precise form of the kernel of decision-making, at least in simple cases.  What of it is deterministic or how deterministic it is, where stochasticity enters into it, and in fact we're in the process — this is something I'm actually involved in.  We're in the process of writing a paper about this called "The Physics of Decision-Making" because literally the model that people are beginning to converge on is one that comes out of physics.  It's just an extremely interesting and, I think, important development that you'll be hearing more about and that I think you need to keep your ear to the ground with regard to it because I think this really sets the stage for answering some of the questions of the sort that came up this morning or, sorry, earlier today.

Another area that is probably more developed than this one is our understanding of reward- based reinforcement learning and how that affects preference.  Some of the studies that you read about in The New York Times about fMRI being able to, as I mentioned earlier, predict whether somebody likes Coke or Pepsi were actually inspired by theoretical work regarding the neural bases of reinforcement learning and how that leads, over time, to people's preference behavior or choice behavior.  And this is something where there is really mathematical knowledge emerging about how these systems work and that are making very specific and precise predictions about neurophysiology, about human behavior.  So that's one important domain, I would argue maybe the most important over the longer term.

The other is "wet" neuroscience.  I put "wet" in quotes because it's not necessarily always involving electrodes, but largely studies that involve neurotransmitters that direct neuronal recordings in nonhuman species.  And, again, it's begun to paint a picture that is interacting pretty tightly with at least some of the theoretical work.  For example, our understanding of reinforcement learning was originally inspired by interest in dopamine and now provides a pretty mathematically precise account of what dopamine is doing, at least in certain circumstances.

Recordings from the prefrontal cortex, an area of the brain that I'll be talking about from a different perspective, is really the origin of much of the work that's being done in humans now; that is, recordings from monkeys performing tasks that are facsimiles, at least, rough facsimiles of the sorts of things that we can have humans do in the laboratory, and perhaps most recently, a renewed interest in orbitofrontal cortex as an important area in the evaluation of actions or stimuli and their consequence for subsequent action.

So these are all — this is obviously a highly kind of edited list of developments, no doubt biased by my personal interest, but just to point out that there's a lot going on in neuroscience that we're not talking about today and that nevertheless is as, if not more, important than the things we are talking about.  So I would really encourage you to find representative experts in these areas and others to come and talk to you about extremely important developments that I'm not going to touch on.

Then there's a third area, neuroimaging studies, which we did spend a lot of time talking about and which I will actually focus on for the rest of my comments.  And I want to start by saying a word about some of the caveats and concerns that one should have about these studies.  Some are obvious.  For example, imaging studies are complex.  I mean, you see this beautiful pseudo- color map on the pages of the Tuesday's Science Times and you think you've actually learned something about the brain, but actually what those pictures don't reveal is the many, many — well, I would venture to say hundreds of hours of analysis that go into — really complicated analysis programs that go into producing those images.  And whenever you have a complicated analysis program, you have to ask whether what you're looking at is what's really going on or what the person wrote the program was biased to show you.

So there's a real danger in interpreting this data without a keen understanding of how the data were generated and, similarly, with how the studies are carried out.  And I'm sure you all are at least roughly attuned to some of these issues.  I'd be happy to say more about them later, if you wish, but it's really important to keep in mind that all of the studies that we do are subject to all kinds of assumptions, of limitations, and it's very tempting to jump on the conclusions without taking account of the uncertainties involved in many, if not most of these data sets.  And that factors directly into the probabilities that Dr. Michels was discussing earlier.

I'll say a word or two about that later when I talk about a couple of specific studies, but that's important to keep in mind.

At the other end, they're really crude.  As complicated as they are, they're telling us very, very crude information.  And again I won't belabor this because this has come up already, but just to drive home the point, we're not actually measuring brain activity with any of these methods that are used in humans.  We're measuring blood flow, and blood flow is a really poor approximation of brain activity.  It's off by about four or five seconds from when the neural activity occurred.  It's occurring on the order of centimeters, maybe millimeters, when neural activity at the level of single neurons is occurring on the order of microns.  So you're off by two or three orders of magnitude in the spatial resolution of at least some of the relevant events.

Now our hope is that nevertheless by summarizing over many kind of probabilistic or stochastic neural events we see kind of the forest for the trees, as it were.  So that in fact, these methods are telling us something of meaning, if not everything there is to know, about neural function.  But that said, they're crude relative to the unit of computation in the brain which could arguably be said to be the single neuron.

So it's important to keep in mind that they're complex, that they're crude, but maybe most importantly and at least most importantly for ethical and moral concerns, is that they're really sexy.  And I mean that in a technical sense.  I mean people love this stuff.  They eat it up.  They want to know about it.  They're persuaded by it and they want more.  And that lowers the thresholds for keeping these considerations in mind.  And so just to make that point, let me show you something that I got off the news I think it was a couple of weeks ago.

I'm sorry.  I've got to move the microphone.  Tell me if you can't hear. 

(Video plays.)

"You've heard the saying an apple a day keeps the doctor away, but a Japanese study finds just peeling the fruit might be enough to do your body good or at least your brain.  Fourteen adults in the study peeled or just touched apples with a knife showed stimulation to their brains.  Those who actually peeled the fruit showed stimulation to their frontal lobes which is the most highly evolved section of the brain."

(Video ends.)

I mean I could just stop there, right, with regard to this point.  I mean maybe there's something interesting in that study, but if it is, it's not what was communicated, right?  And this is scary because it means in courtrooms, on the floors of Congress, in rooms like this, brain imaging data carries a persuasive and deceptive, a persuasive and deceptive ability that really has to be cautioned against.  Okay?

Maybe that's the most important thing I have to say to you today because this is already on the minds of marketeers.  I've had unnamed, but very well known and reputable and influential concerns, commercial concerns, approach me with an interest in doing brain imaging studies.  And when I told them that I thought their behavioral measures were actually much better than what the brain imaging data could tell them right now, they said they didn't care.  And I said, well, why don't you care; and they said, well, can you just show us that Product A is going to activate an area of the brain that Product B doesn't.  Well, sure, but Product B will activate a different area.  Well, we don't care.  We're going to go into the pitch with the picture that shows Product A.

And I was tempted to say, well, you know, give me my consulting fee and promise you'll never publish it and sure.  But, I mean, that tells you the power of this method and the perverse uses to which it could easily be put.

I'm sure I'm not telling you anything you don't know, but I think it's really important to punctuate that.  And I think maybe the most immediate ethical concern you have is exactly this:  what to do with the status of these sorts of data which very easily outstep their actual — their legitimate bounds.

Okay.  With those caveats, I am going to tell you about brain imaging data, hopefully though with a little bit more responsibility than that news report.

What I'm going to do is tell you about two studies that we did.  I hope I'll have time to get through both.  I'll go through the first one in a little bit more detail because it will require a little bit more explanation with regard to the methods and then maybe whisk through the second one just to make the higher level point.  But both are designed or chosen to make a higher level point about what we're learning about the nature of the brain and how that gives rise to people's higher level behaviors.  And in this case I picked moral decision- making and economic decision- making as two examples of high level behavior that may begin to change our view of what economic decision- making is about and what rational behavior really is and what moral and ethics is about, at least as it's practiced.  So an issue that's already come up is does this sort of information have any prescriptive value or is it just descriptive.   And at the moment I adhere strongly to the stand that it is just descriptive.  I'm certainly not licensed, nor do I feel qualified, to tell you what prescriptions it should engender, nor do I feel that the data themselves are yet reliable enough for those of you who are licensed to do so, to do that with these data

But the point is that sooner or later I think they are going to give us reliable data that are going to raise prescriptive issues, some at the level of policy with regard to individuals that Dr. Michels talked about, but, I would conjecture, some at the very most fundamental level of what it means for something to be moral or ethical.

And I know this is a contentious point.  It's one that I think begins to address the question that was asked earlier about the kind of epistemological status of these data.  Again, I don't want to say that the data I have are at that point, but I think that over the longer term, neuroscience can begin to shape how we view ourselves as ethical and moral creatures or as rational creatures and may even inform us about that in ways that will lead us to change it.  And that's the most fundamental kind of impact that neuroscience could have, and I think very well might have.

So the two examples I picked.  One is about how people are kind of inconsistent in their moral behavior and the other is how they're kind of suboptimal in their economic behavior, and I'll explain what I mean by that in a moment.

The question they pose for me is:  Why do people behave in these,loosely said, irrational ways?  Why are they inconsistent?  Why are they suboptimal?  And I'm going to offer some speculations that have to do with evolution.  I'm not an evolutionary biologist, so I'm getting well beyond my expertise here too, but I find it impossible not to consider this, and again I think it helps illustrates the sorts of fundamental questions that these data can raise.

And I'm going to offer a conjecture at the end that I will describe, and in so doing so, define for you what I mean by vulcanization.  I'll leave that as a little mystery until I get to the end.

Before I go any further, I want to acknowledge the people who really do the work.  At this point, I'm just kind of the mouthpiece for some really talented and devoted scientists who are really not only technically gift, but I think are giving really hard thought to some of the questions that are being discussed here.  In particular, Josh Greene, who did the study on moral reasoning that I'll talk about; Lee Nystrom, who runs my lab and actually oversees all the imaging studies and then Alan Sanfey who is not pictured here — this is when we first got our scanner — but was responsible for the study on economic decision- making.

Okay.  So let's start with the moral decision- making test.  Here's a dilemma that moral philosophers have been toiling with for the past couple of decades.  It's called the Trolley Dilemma.  Some of you are probably familiar with it, but under the assumption that not everybody is, I'll go through it quickly.

There's actually two scenarios that constitute the dilemma as a whole, and I'll describe each one.  In the trolley scenario, there's a trolley or a train coming down a track and it's actually — these pictures are not the best, I apologize.  But it should be showing that the switch on the track, there's a switchpoint on the track and it's set so that it's going to come down and kill these five workers.  But you're a switch operator on the track far enough away from the junction itself that you can't alert anybody, but you can act quickly enough to flip this switch which would cause the trolley to go along this track instead of this one, killing this workman instead of these five.  And the question is is that an ethically or morally acceptable action?  I'm not asking how difficult it is, whether you would like to be in this situation, whether you actually would bring yourself to do it, but simply the abstract question: Is it morally or ethically sound to flip that switch?  And let's just take a poll.

Those of you who think it's ethically sound to flip the switch, please raise your hands.

PROF. GEORGE:  Who are the guys?

DR. COHEN:  They're workmen.

PROF. GEORGE:  We need a little more information.

DR. COHEN:  Actually, thank you for asking that.  Let me —

DR. KRAUTHAMMER:  Republicans.

DR. COHEN:  — do two things here.  First of all, let me caution you about the fact that these — we could easily spend the next two days talking about some of these issues, and so I'm going to try and curtail a discussion about the ethics here, at least until the end so I can get through the material.  On the other hand, if anybody has questions — because I'm presenting semi- technical material.  If people have questions of clarification that require me to say a bit more for you to understand what I'm talking about, please don't hesitate to stop me.  But what I don't want to do is get sidetracked into the ethical conundrums because literally this could take hours.

That said, that's a good question, and let's assume they're workmen.  And you'll see that the next slide is flawed in that regard, and so I'll correct it.  I'll describe what the slide should show when I get to it.  But assume in all cases the people influenced are workmen.  So they've kind of signed on to this job.  They know the risks, dot dot dot.

So most people, as I saw it, raised their hand, not everybody, interestingly, but most people raised their hand and said that they thought it was morally acceptable to flip that switch.  Now let's consider another scenario and instead of this being a sumo wrestler, let's imagine it's a very large workman and he's repointing this bridge here — you know, the bricks — and he's kind of leaning precariously over the edge and again, you're a bystander.  You notice that the train is coming down the tracks, and it's going to kill these five workmen, only this time, in order to save them, what you'd have to do is push this large workman off the edge of the bridge.  He's large enough that he'll stop the train.  You're small enough that if you jumped and committed suicide, you wouldn't stop the train.  I mean, allow me all the contingencies here to set up the dilemma in the way you know I want to set it up.  And as a matter of fact, we empirically tested most of these, so all of these assumptions kind of bear out.  The finding is general to the issue and not to the specifics of this particular circumstance as you'll see shortly, actually.

But the question now is is it morally acceptable for you to push this guy off the edge, on the assumption that you're going to succeed as effectively as flipping the switch on the other one, and have him take the hit and die but spare these five.  So many people feel that that's a morally or ethically acceptable thing to do?

Fewer hands went up.  A couple came up late.  So it took a little longer for people to say, for everybody to say whether or not that was acceptable, but certainly many fewer.  That concords with the empirical data that we have when we test these two scenarios in particular and a number of related ones that we actually went on to use in our imaging study, that 90 percent of people say that it's okay to flip the switch, but we get exactly the opposite for pushing the person off the bridge.

Now obviously what's interesting here is that the actuarial statistics are the same.  It's five for one, right?  And so why is it that people feel that in one case it's acceptable to sacrifice a life, play God in effect, right, by influencing the outcome of the events and spare five at the cost of one, and in the other case, it's not acceptable?

Now I know spinning through your heads are 15 or 20 or 100 different conjectures.  Let me offer you one, okay, to satisfy you that we're not dolts and that we've thought about this as intensely as we can and, hopefully, as intensely as you might to come up with as many possible accounts as one could imagine, attendant to the literature and all the possibilities, and controlled for that in the various scenarios that we've used to limit it to — with the outcome being that there's still a conundrum, that there's no simple account that really explains it.

So let me give you one possible account and show you how we can dismantle that one and then hope that you take it on faith that we've done similarly with all the others.

Well, one can say that one important difference between these two scenarios is that in the first case, the guy standing on the sidetrack was dying an incidental death; that is, there was nothing instrumental in your use of him.  You would have been much happier, in fact, if he wasn't there.  Then it would be a no brainer.  You'd just flip the switch, right?  But the fact that he's there is unfortunate, but not consequential to your being able to save the five.

Whereas, in the second case, you had to have that guy there.  If he wasn't there, the five men are dead.  There's nothing you can do, right?  So you're actually using that individual.  He's an instrument of your actions and that maybe we have an aversion to using people as instruments and that that's what leads to this moral intuition.  I'm not saying that you calculated this consciously, but at some level maybe you were attuned to that possibility.  And, in fact, Kant suggested exactly this in this philosophy.  He said never use on people as means, only as ends, and that that was a fundamental moral principle to which we should adhere.  And maybe that's what people are doing.

Well, at least in this case we know that's not what they're doing because if we change the scenario just slightly by adding this little bit of track here, such that if you flip the switch and the train comes down here and this guy wasn't there, the train would come around and kill these five — you still don't have time to warn them, okay?  — it doesn't change people's intuitions and yet now that person has to be there.  If they're not there, the train will come around and kill them.  It's because they're there that you're using them, you're using their presence there to save these five.

So it's a purely instrumental case, just as the footbridge scenario is, and yet this doesn't change people's intuitions.  When you give people this dilemma, they're as likely to say flip the switch as they are if this bit of track isn't there. 

So that alone can't be the principle that people are using.  And now again, if you'll allow me that we've considered many other possibilities, professional status, whether they're part of your racial group or not, there are a lot of variables, admittedly, in these particular scenarios, but we've tried to control for them in versions of these scenarios and we've used a bunch of other scenarios that vary in a whole bunch of different ways.  And we, at least, have not been able to come up with any systematic rationalist account - B rationalist in the sense that Kant intended it, okay? — that causes people to systemically go with the ones that they say are  ethical and not with the ones that they don't.  And if you don't trust me, then the materials are on a website and you can go and look through all the materials and tell us whether you can find some systematic principle that caused people to go one way with one set and the other way with the other set.

Our hypothesis — I should say Josh Greene's hypothesis.  He was really the impetus for this work.  He was a graduate student of philosophy when I arrived at Princeton and was the first person to kind of knock on my door, when I got there and was building a brain imaging facility, to say he wanted to do a study.  And I've got to say I really knew I was at Princeton when it was a philosopher that walked through my door and not a neuroscientist, you know, to want to do a brain imaging experiment.  But it didn't take but five minutes of talking with him to convince me that this guy is an incredibly gifted, thoughtful guy and had a really interesting program of research to pursue, and so I really want to take a moment to credit him with most of the thinking and kind of motivation for the study.

And it was his hypothesis — and certainly I shared the intuition with him — that what explains the difference is an emotional response that you have in one case and not in the other.  Okay?  That the thought of pushing a person off a bridge when you're close at hand is emotionally more salient than flipping a switch when you're several hundred feet or several miles away from them, and that these sorts of emotional reactions have an impact on people's moral decisions.

Now this is a descriptive claim, not a prescriptive claim.  We think this is what happens in the real world.  It's what explains behavioral data of the sort that we just collected, not necessarily the way it ought to be.  But, nevertheless, it's a strong claim and philosophers have tried to reject this claim, and the question is how do you test it. Right?

So you can ask people whether or not this concurs with their intuitions and some may be forthcoming and insightful enough to tell you, oh yeah, that makes sense, but others may not.  Either they may not realize they had an emotional reaction that at some level of the unconscious they actually did have.  Psychodynamic theory and psychoanalysis is not entirely dead, Mike.

Or perhaps they are aware, but, like many people in our society, are unwilling to admit that emotions will impact their decision and so won't tell you about it.  And so how can we assess this hypothesis that emotions are influencing people's moral decision- making without asking them?  And, you know, one way is to use long- standing, relatively well characterized measures like galvanic skin response.  When you get emotionally aroused, your skin conductance goes up and you can measure that.  And in point of fact, we've done that and it provides results that are, in the end, not quite as clean as the imaging study.  It's a lot cheaper, you might think.  We were in the perverse circumstance of having a brain scanner sitting there that was easier to use and that we knew how to use better than a couple of electrodes and a small resistance box or capacitor box.  So I have to confess that expediency led us to neuroimaging in our case as much as anything.  But what I hope to show you is that the results, actually, told us much more than I think a simple GSR experiment would have told us.

So our hypothesis was that emotions account for the variance across the different categories of dilemmas that seem to pose the sort of — elicit this inconsistent behavior and that we could test this by putting people on a brain scanner and measuring their brain activity when they considered these sorts of dilemmas and were asked to make decisions about them.

So now this wasn't totally out of left field.  There's certainly a long tradition of human neuropsychological research that suggests that there are parts of the brain that are involved in processing emotion.  I certainly concur with Dr. Michels' view that the distinction between cognition and emotion is nowhere near as clean as we would like it to be or as we often treat it.  But that said, there is a meaningful difference there and it seems to be reified at least in part with what brain areas seem to be computing emotionally charged or valenced decisions and which ones don't.

And some of the earliest data come from brain damage, so I'm sure you're all familiar with the case of Phineas Gage who was coincidentally a railroad worker.  I don't think he was hit by a trolley coming down a track that somebody failed to flip the switch on.  In fact, I know he wasn't.  He had an accident with a tamping iron that sent this big rod through this frontal cortex.  And the remarkable part of this story is that the guy lived to walk away three or four weeks later in perfect physical health and lived many, many years after that.

The sad part of the story is that his personality was forever changed and it was changed in just the sorts of ways that you might predict if it hit the part of the brain that was responsible for integrating emotional evaluations or maybe even moral and ethical evaluations with behavior.  He was a very responsible, kind of adroit citizen, a well- regarded foreman on the team on which he worked, and after the injury he became somewhat of a kind of a rascal.  He got himself into trouble with gambling, he couldn't manage his finances, he became lascivious, he made lewd comments in public.  His whole, what we would call, his moral fiber seems to have changed.  And that led to early conjectures that this front part of the brain, the prefrontal cortex, a particular part of the prefrontal cortex, was an important, if not the sole determinant of moral and ethical behavior.

So the idea that we might find brain areas that were specific to these sorts of tasks was not totally uninformed.  So we went ahead and put people in the scanner, and we used MRI.  And I was asked to say a word about these methods.  I won't go into too much detail, but this, I think, gives you a graphic depiction of the kind of physical detail that we can get from a single brain.  This is a half- an- hour scan.  Nowadays you can do — this was done about ten years ago.  This scan can be done now in about five minutes.  You can get a picture — this is a graduate student at my laboratory, then a graduate student — a picture of their brain that shows every last little fold of their brain.   So at least with regard to the anatomy it's pretty remarkable how much detail we can see. 

Up until about ten years ago you could only see this sort of thing, so you could tell whether or not somebody had cancer maybe by seeing whether or not there was a growth.  You could tell whether or not they had Alzheimer's by — well, you actually couldn't tell whether they had Alzheimer's, but other forms of degenerative disease you could diagnose by seeing whether there was loss of tissue, but what you couldn't see is what areas were functioning when people did particular tests.  That all changed about ten years ago when several groups realized that using the very same machine and trying to make the same measurements with that machine that are, in effect, made with PET scanning — that is, measuring blood flow — you could index brain activity with a remarkable degree of precision, remarkable with respect to what you could do with PET scanning at the time and with respect to the fact that it's totally non- invasive. 

Every once in a while I go down to the scanner still and I watch what's going on and I still get the heebie- jeebies.  I mean it's really like an episode out of Star Trek.  Twenty or 30 years ago, Gene Rodenberry gave us an image of one of these scans that somebody would lie in and Bones, the doctor on the ship, would be able to tell what was going on.  Never a needle prick, never any radiation and that's effectively what we're able to do.  It would be in crude form, but in a totally, as far as we know, non- invasive way.  We can tell what areas of the brain are activated when somebody is doing a test. 

So here's an example of people looking at a chess/checker board.  And areas that we know from other sorts of measurements are involved in visual processing light up and other areas that are not involved in visual processing don't light up.  So this is a particularly good case of our ability to be both accurate and precise in our measurements.

There are perils to this method.  I've already mentioned a few.  I want to mention one conceptual one because it too comes up frequently in discussions of brain imaging, and it raises concerns, but I think also sometimes overstates those concerns, and that is the idea that all we're really doing is reinventing something that was discredited a long time ago, namely phrenology.

So Franz Gall, about 150, almost 200 years ago now, had the idea that different parts of the brain represented different functions.  Now for my money that was a major insight, and it took a long time for it actually to take hold.  But he was the leader, one of the leaders in the pack, in realizing that the brain is not an undifferentiated mass of tissue, but that different parts of the brain actually carry out distinguishable functions.  How distinguishable, we can debate.  But there are characteristic functions in different parts of the brain.  The back of your brain  handles vision; and if you cut it out, you're not going to see very well. 

Now he reasoned from that that if different parts of the brain had different functions and some people had those functions better developed, maybe it was because they had more tissue allocated to those functions and that, in turn, would occupy more space which means that the cranium had to accommodate it by getting larger and therefore he could diagnose who was more reasonable and who was a better lover by feeling bumps on the head.

Now that version of the story or that inference, of course, is wrong and it's silly.  And when people referred to neophrenology they're talking about brain imaging experiments as being just a reinventing of bumps on the head only now it's pseudocolors, right? 

And an important point that's made by that is we have to be careful about not being too simplistic in our idea of how the brain works, even though there's a part of the brain that's responsive to visual stimuli that doesn't mean that all of vision, all of object recognition, your ability to kind of appreciate the smile on your wife's face when you wake up in the morning is all housed in the visual part of the brain because it's a visual stimulus, right?  The brain is a highly interactive and intricate mechanism that's integrating all kinds of information at every point in time.  And so the fact that there's some specialization of function doesn't mean that the functions that each part of the brain is specialized for map on to functions that we recognize at the surface.  They may be much more complex and intricate sorts of functions that don't correspond to simple sorts of things like vision and smell.  Some may, but some may not.

So the idea that there's a reason area or a love area may be right or it may be wrong, and the fact that we can see areas of the brain activate when we give somebody a love test, doesn't mean that that's the love area of the brain.  That's the right criticism of neophrenology.

This is just to say that even those ideas, bad ideas die hard.  I got this off the web a year or so ago.

(Laughter.)

Some people still believe in old Franz Gall's diagnostic techniques.  But that said, it is important to realize that the brain does have functional specialization, and we can leverage that for scientific understanding and maybe even for better understanding of who we are as individuals and as species.  So, for example, if I know that there are some areas of the brain that reliably activate when emotional stimuli are presented, then I can leverage that observation, that prior observation to ask whether those areas are activated when I give somebody a footbridge type scenario as opposed to a trolley type scenario.

So another way of saying this is that a map, as such, is useless, but a map is extremely useful if you want to go somewhere.  So neophrenology is useless if that's where you stop, but if you're going to use that map, with all the proper caveats applied to it, to understand how things are happening in the brain, then it may be actually a valid endeavor.

Okay.  So the last bit before I tell you about the experiment is to say how did we kind of systematically manipulate the emotionality of the moral dilemma.  We had to operationalize this idea so we could do an experiment, so we could have some that were emotional that were like the footbridge problem, and others that weren't that were more like the trolley problem.  But we didn't want to use — we couldn't use the same dilemma over and over, so we needed lots of dilemmas to be able to test this because we have to do signal averaging.  One of the problems with these methods is that a single trial doesn't tell you a lot.  There's a lot of noise in the data.  So you have to perform the experiment 15, 20, sometimes a 100 times and then average over all of those to take out the kind of noise and see the signal you're looking for.  So for that, we needed lots of dilemmas, and for that we needed a way of characterizing ones as being either footbridge- like or trolley- like.

And so we used these criteria.  The dilemma was emotional if it was up close and personal; that is, if it can be expected to cause serious bodily harm B it wouldn't be immoral otherwise — to a particular individual as opposed to a statistic, to an undescribed body of people and through proximal action.  And Josh and I actually differ as to how important this is.  I happen to believe this is the most important one as you'll see shortly.  He's not as convinced by this and we're doing experiments to try and test that.

But in any event, these were the criteria that we used, and it was meant to capture the sort of kind of primitive notion of me- hurt- you.  And, again, this will factor into my comments in just a few minutes.  So "hurt" is the serious bodily harm, "you" is a particular person, and "me" is the direct proximal action.

And so the experiment involved the subjects going into the scanner and we gave them 60 dilemmas, 20 that were moral/personal, defined in this way — sorry, we generated a bunch of dilemmas and then we had people rate them on these criteria.  And then we took the ones that were rated as satisfying these criteria and called those "moral/personal" and presumably thereby invoking emotional responses.  We took the ones that didn't satisfy these criteria, reliably didn't satisfy these criteria as "impersonal" and then we included a control set that were meant to just control for all the other things that people have to do in these experiments: read the materials, think about them, maybe agonize a little bit over what they're going to do or what answer is right, be on the spot, all the kind of incidental processes that we don't think are relevant to what we're interested in that we try and control for in our baseline condition.

And so for that condition we invented 20 kind of cognitive puzzles that roughly took the same amount of time to solve as people took to answer the moral dilemma ones so that we were controlling for time on task.

And when we do the experiment, we get a bunch of areas that are activated.  So we compared these moral/ personal ones against the nonmoral ones as a kind of baseline or control.  We compared the impersonal ones against the baseline or control.  And we asked what areas showed greater activity in one of these two conditions as compared to this one, as evidence that they were specifically involved in the processes involved in solving this type of problem, this type of problem versus this type of problem.  Is that clear to everybody?

This subtractive methodology is kind of at the core of most studies, and it too is subject to many assumptions and therefore many potential problems.  When done properly, it's extremely powerful and has been validated to tell us information that can be independently confirmed with other methods, but it's also easily abused.  So here's another place where if one wants to evaluate a particular study, one really has to look carefully at how these comparisons are made and what this condition looks like.

So when we do this, we found a series of areas, not all of which are shown here, but some of the critical ones are shown and I've colored them red or blue to roughly connote what the prior literature in neuroimaging had suggested about the function of these areas.  The ones coded or colored or kind of backgrounded in red are areas that in most previous studies that have reported them have involved emotional stimuli or emotional decisions or emotional circumstances that the subject had to apprehend or interpret or whatever.  None of them were moral, but all of them evolved emotions in some way.  And this one here and a few others that I'm not showing, the prefrontal cortex, the parietal cortex that I've kind of backgrounded in blue, are ones that typically are not associated with emotional stimuli, but are associated with cogitation, as it were, with kind of mental problem- solving, working memory.

DR. FOSTER:  One question: Are those outlined areas of change which you've just colored in or are these stylized diagrams in the area?  Are these the raw data?

DR. COHEN:  No, these are absolutely not the raw data.  Let me tell you what you're seeing.  You're seeing three things.  First of all, kind of as a background, you're seeing a structural image of the brain so that you can — for those who know something about the brain, they would be oriented as to where these areas are, okay?  So that was not acquired at the same time, but it was acquired in the same subject.  So we're overlaying these areas of activity on an image of the person's brain or, in some cases, an average of all of the subjects' brains that we studied.

The colored areas here are statistical maps.  So where it's red, there was a much greater signal associated with — well, you'll see what the signals were associated with.  But there was a much greater signal, either in the moral personal or the moral impersonal compared to the control, and the colors code the degree of statistical reliability with which those areas were more active in the experimental conditions than the controlled conditions.  So they're not raw data, but they're statistical analyses of the raw data.  They're quantitative data.  They're not graphic renderings.  These are derived from real statistical analysis of the actual data.

And then I've just drawn these circles here to draw your attention to those areas.  Does that answer your question?

Okay.  Now we can ask, well, these are areas that, as I say in the past have been associated with either emotion or not, how do they activate in our moral/personal versus impersonal conditions or non- moral.  So actually here I've plotted the activity in these areas including in the moral, sorry, the non- moral condition against baseline, against just plain rest where the subject isn't doing anything.  And what I want you to see from the slide is that all the areas that are associated and that have been associated in the past with emotion activated in the moral/personal condition for moral/ personal dilemmas when the subject was contemplating and deciding about those, and not in the moral/impersonal or, in any event, much less so in the moral/impersonal or non- moral conditions.  And the exact converse was true for the areas that are associated with cogitation, the working memory or problem solving.  They tended to be more activated in the non- moral and the moral/impersonal conditions and not in the moral/personal.

So emotional areas seem to be engaged when people were contemplating dilemmas like the footbridge problem and non- moral, but kind of higher level cognitive areas were engaged by the moral/impersonal, the trolley- like problems and then, as predicted, kind of abstract problem- solving tasks.

What's even more interesting I think, and this is more the result of actually an extension of the original study that — these results, by the way, have been replicated three times now, twice in our laboratory and once in one other laboratory.  So I'm pretty confident that these are reliable effects.

What's even more startling is that when we look across many different experiments and start to correlate the extent to which individuals make a utilitarian decision — that is, they say, look, even though it's emotionally kind of aversive to me, to think about pushing that person off the bridge, I'm going to do it anyway, okay? — you get more activity in prefrontal cortex.  And if you look at the people who are most utilitarian, the correlation is really quite startling, about .9.  And you can see that that's not being driven by outliers.  That the more — when people make utilitarian decisions, that prefrontal cortex seems more active than when they don't.  So that this particular area of the brain is not just overall correlated, but almost begins to have the feeling of being predictive of when they're going to make a utilitarian versus a non- utilitarian decision.  And I'll say more about that kind of data analysis when I talk about the economic decision- making test.

Okay.  So some inferences from these data: emotional responses can influence moral judgments.  I'd like to infer that.  There are additional data that I don't have time to tell you about that are behavioral data that suggest that this isn't just correlation but actually is cause.  That is, these areas aren't kind of incidental activations associated perhaps with the discomfort of having to make a decision, but rather precede it and actually, as I said just a second ago, predict the outcome of the behavior.  I don't have time to go into that in this experiment, but I'll say something about that in the economic decision- making test.

Not all moral judgments elicit emotional responses.  They occur to proximal interactions, me hurt you.  They don't occur from more distal interactions, for example, flipping the switch.  And, furthermore, the competition between prefrontal areas and emotional areas seems to be at the heart of or at least an important component to what the outcome of this decision is.

Now I want to offer in this context a little hypothesis, and this is really armchair theorizing.  It's no more than that, but it's provocative, and I think it's usefully provocative. 

Why do people have these emotional responses?  Well, one hypothesis would be that they reflect evolutionary adaptations that favor prohibitions against inter- clan violence.   That is, to the extent that we were successful in evolving as a social species and that we came genetically wired with mechanisms for aggression that protected ourselves and what we had accrued, we needed to somehow kind of stop that from happening among those with whom we were starting to cooperate, or else the threshold for cooperation would be too high and we wouldn't succeed, right?  That puts it teleologically, but I think you get the drift of the argument.

So one can imagine that these emotional responses or the brain systems that mediate them evolved as a way of controlling our aggressive tendencies to those with whom it would benefit us to cooperate.  Now evolution is opportunistic, right?  And so it optimizes mechanisms for the circumstances in which it finds itself, for local prevailing circumstances and not at all possible circumstances in which these mechanisms were developing.  The only way we could do damage was through proximal cause, by hitting somebody, or picking up a stick and bopping them on the head, right, and not by flipping a switch and causing some damage a few miles away, no less hitting a button and causing many millions of deaths many thousands of miles away.  We just didn't evolve brain mechanisms to deal with that.  It just wasn't in our environment.  It wasn't in our circumstance, and so the brain just never developed mechanisms to deal with that.  And so our emotional responses are circumscribed to the the circumstances that we found ourselves in evolution and maybe no longer are the only ones that are relevant.  So hold that thought and I'll come back to a similar sort of argument when we get to economic decision- making or the end of economic decision- making.  All right, so that's the moral decision- making experiment. 

Economists are as interested in rational behavior, maybe even more so, than philosophers, and again as I'm sure most of you know, the standard economic model assumes that, in fact, we are optimal; that is, rational decision- makers, that we always choose the action or the good that is going to maximize our utility, maximize our personal gain and that we do that optimally.

And they make that assumption for a very reasonable reason and that is to be able to have traction in theory.  That is, it simplifies a lot of matters when you assume people are optimal because you can do proofs about optimality, right?  You're stuck doing statistics on what people actually do.  So I think it was actually just a tactic that led to a stratagem in economics.  That's another story.

In any event, economists have long assumed that people act rationally, and they got away with it for about 30 or 40 years, but the development of behavioral economics has begun to catalog a large number of instances in which people don't seem to act anything like the way economists say they should.  And in fact, the Nobel Prize was given out this year for that work, to Daniel Kahneman and Vernon Smith, among others, who have kind of championed this area of behavioral economics.

And we were really interested in this, in part, from my perspective because of the parallels that it draws with the moral reasoning work, but because I think it has intrinsic interest in its own.  Understanding what the basis is of economic decision- making is just as interesting as the basis of moral decision- making.  And so we used kind of a similar strategy.  We picked a task that we thought highlighted, in this case, the suboptimality of people's behavior and then scanned them while they performed this task and looked at what the brain was doing when they made what seemed to be optimal decisions versus non- optimal decisions. 

In this case, the task was rather a simple one.  It was called the Ultimatum Game.  Subjects were paired with a partner who they met before the scan and were introduced, actually were ten partners.  They were going to play with all ten of them.  They were introduced to them, and while they were in the scanner, they were shown pictures of who it was that they were supposed to be playing with.  And in each case, the partnership was offered a sum of money, let's say $10.  So let's say Dr. Kass and I are offered, as partners, this $10, and I'm in the scanner.  So it's Kass' job to decide how we're going to split it.  So you can decide to give me $5 and you'll keep $5 and then it's my option to either accept the offer in which case we each get the allotted sum or to reject it in which case neither of gets anything.

So you offer me $5, you keep $5, I say sure, he's a fair guy, that's a fair deal.  I take it.

But what if you offer me $1 and you decide to keep $9?  Or what if you decide to give me a penny and keep $9.99, what do I do?  Now the economists say you'd take the penny, right?  You're not going to get anything else.  If you reject it, you don't get anything.  Now you can get sophisticated about this and say well, but you want to punish him so that next time he'll give you a better offer.  You want to establish a bargaining position.  But we set up the game so that subjects know they're only playing it once with each individual.  Well, maybe they want to protect their reputation.  They don't want that guy to tell the next guy, right?  We tell them that it's totally confidential, the outcome of each individual interaction is not going to be imparted to anybody else.  Now you can question whether or not they believe it, but there's a whole line of work using this task behaviorally that shows that, in fact, you can convince people that these conditions are, in fact, so.  And, nevertheless, people still reject the penny or the dollar or even $2 up to about $3, okay, and get nothing, in effect, just to kind of punish the other guy.  And so the question is why do they do this?  I think that's summarized.  And this is just a behavior evidence that they do.  This is actually from our study, but this totally mimics what's observed in the literature, that subjects reject offers at around 20 to 30 percent.  In this case, it was 20 percent of the total pot and they accept it when it exceeds that.  So if Kass had offered me $3, I would taken it, but if he offered me $2, I would say screw you, we're both going to get hurt here, but I don't care because maybe it gives me pleasure to hurt you for having tried to rob me. 

I won't get into this, but it's interesting that the response times are longer for fair than for unfair offers.  So, again, the question is: What's happening?  Why are they doing this?  And so I've already said a couple of reasons and rejected them, bargaining position.  Maybe they want to — well, bargaining position or reputation.  The situation is such that that doesn't make sense.  Maybe they want to punish their partners, but that just begs the question why do they want to punish if they're never going to interact with them again.  So it really doesn't give an answer.

Again, we're left with the answer that there's some irrepressible, negative emotional response that they have that causes them to do it.  So, again, we can test this by putting them in the scanner and looking at what happens when they accept offers versus reject offers, and that's exactly what we did. 

Again, we got areas of the brain that were activated in the task as compared to the baseline.  We got our same player, the prefrontal cortex.  This was also in the other study, the anterior cingulate cortex, but I didn't say anything about it, and then critically, in this case, the insular cortex.  And what's really interesting though is that if you look first at the population level, people who accepted versus rejected the offer, generally speaking their — in people who accepted the offer, their prefrontal cortex was activated about ten percent more than people who rejected on the offer.  And exactly the opposite was true for the insular cortex.  So it looks like if your prefrontal cortex is active or if you're going to accept the offer, your prefrontal cortex is going to be active and if you reject the offer, your insular cortex is active.

Now the insular cortex is an interesting area.  It's an area that has repeatedly been associated with physical revulsion, with interoceptive pain, with real aversion, in some cases again, physical aversion to stimuli.  The classic neuroimaging experiment with the insula was one done at Harvard in which they took people with obsessive- compulsive disorders — (how they got this past the Human Subjects Committee I'll never know).  They took people with obsessive- compulsive disorder, put them in the scanner, then took soiled rags which they said had been soiled with human feces and threw it on the subject and the insular cortex lit up like a Christmas tree.

Now the study itself raises ethical questions of its own which we might debate, but it certainly points out that the insular cortex is an area that is engaged in negative or aversive emotional responses and here we're seeing it activated when people find an offer, in effect, revulsive.

But what's even more interesting is that if we go trial by trial, so we take all the trials in which individual subjects, sometimes they accepted the offer, sometimes they rejected it, and we looked at what was their brain doing before they made the decision.  If the prefrontal cortex was more active than the insular cortex, they accepted the offer.  If the prefrontal cortex was less active than the insula — the insula, in effect, broke through the activity of prefrontal cortex — they rejected the offer.  So it's as if the outcome of the behavior again was being defined by this competition between this prefrontal area and a, I might say, more primitive area of the brain that's coding the emotional response.

And I think that we can come up with a hypothesis here that's very similar in character to the one that we came up with in the case of moral reasoning, that maybe this emotional response reflects an evolutionary adaptation that favored protection of reputation.  And this makes sense if you imagine that, as we were evolving as a social species, we were much more likely to come into contact with people that we had had previous dealings with again, right, than we are in modern society.  And so it behooved us to develop very quick, hardwired responses to protect our reputation because it was going to come back and haunt us much more than in modern circumstances where, you know, you got some guy making an offer on a house, and at first they come in at your asking price and then they concoct some story when they do the inspection that the basement is leaking, and you know it was because there was a little bit of water that your kid left down there when he took off his swimming trunks and you know that he knows it, but it's a way for him to get an extra $1,000 off the price.  And you say,to hell with it, right?

Now there's no sense in which that makes sense. You're never going to see that guy again.  Your reputation isn't going to be established, right?  You might as well take the $1,000 hit and sell the $100,000 or $200,000 or $300,000 house, whatever it is, right and be done with it and yet you can just imagine yourself, I suspect — I don't know, I can imagine myself — getting hotheaded, right?

So once upon a time that made sense, but in modern society it doesn't.  So we call that irrational in modern context or in the experimental situation where we told people explicitly, no reputation, no bargaining, right?  They still have this hardwired response because of evolutionary circumstance.

So let me just end then with kind of a playing out of that idea.  I called the talk the "Vulcanization of the Human Brain."  The term "vulcanize" at least according to Merriam Webster's means the taking of a crude or synthetic material, rubber, in the case of industry, and then giving it useful properties.

So what I would like to argue is that the development of the prefrontal cortex has, in effect, vulcanized the human brain.  What it's done is that it's given us the ability to surmount older evolutionary adaptations and consider what we might recognize as more rational decisions, right?  And when the prefrontal cortex comes into play, people can actually bring themselves to push somebody off of a bridge or accept an unfair offer because they know they're not getting anything else.

What's interesting though — so the development of the prefrontal cortex is vulcanizing the human brain by giving it the capacity for cognitive control.  What's interesting is that that very development, I would argue, has created exactly the contexts in which those older evolutionary adaptations are no longer adaptive.  So, for example, in the case of the moral reasoning study, it's created the technology, it's because of the development of the prefrontal cortex that we have the capacity to produce technologies like switches on trains or buttons in nuclear arsenals, right, that control nuclear arsenals, that can do damage at a distance. 

Similarly, it's the development of the prefrontal cortex that supports the complexities of modern society in which social structure can occur in a much wider scale in which we don't have recurrent interactions with everybody that — with whom we've dealt with in the past.

So at the same time the prefrontal cortex solves the problem, it's solving the problem, in some sense, that it created.  And in so doing, insofar as there's not uniformity of prefrontal development, whether because of circumstance or genetic structure, I know not, but because there's not uniformity, and because it only takes some prefrontal cortices to create a circumstance in which other brains that don't have as strong prefrontal cortices can exploit, we are in great peril and I think this raises really important sociological, as well as ethical and moral, issues.

So the prefrontal cortex is precisely the part of the brain that permits rational decision- making in the face of competing evolutionarily older emotional responses.  The vulcanization of the human brain can save us from those circumstances it created, but we're kind of in this delicate stage right now where it's not as if we all have prefrontal cortices that know how to deal with the responsibility to deal with the things that the prefrontal cortex was created.

This is the other sense in which — I thought it would be perhaps a little too cute to call it "The Vulcanization of the Human Brain" because science fiction often anticipates the issues that science later has to deal with and I think Gene Rodenberry anticipated exactly this issue when he kind of designed his character Spock and the species that Spock is a part of, the Vulcan species.  For those of you who don't know about Star Trek, the Vulcan species was a species that literally had a more developed prefrontal cortex and was totally rational and was able to come to social decisions through rational  choice and acknowledged that there were emotional forces in the brain that influenced behavior, but they somehow circumscribed those and expressed them one day or one week a year or something.

But one has to wonder what the path is going to be for us to getting there.  And I picked this as one example of an alternative in the real world where there are traditions and cultures that have looked for rationalist theories, and I picked this to be again provocative.  There are certainly ones in Western culture as well that seek to kind of deal with these issues of how rationality can be exploited in a world in which not everybody is rational.

I've made this point already, that it takes relatively few rational agents to create things that many more people can put to irrational use, and so there's this race.  This actual last point is more for my scientific colleagues as a kind of a challenge for how we can deal with this knowledge, but I present this issue to you because I think it's transparent, the sorts of ethical questions that come into focus in now concrete and measurable ways that wasn't so without the sorts of tools that we have available to us now.  So I can stop there.

(Applause.)

CHAIRMAN KASS:  Thank you very much.  Frank and then Michael.

PROF. FUKUYAMA: Well, thank you very much for that presentation.  I guess in a certain sense you've answered the question that I was trying to pose to Dr. Michels about how precise the technology is.  My general impression is you've got to drill down a couple of orders of magnitude more before you get to a lot of the things that have been speculated on.  But I guess in reaction to the presentation about the moral reasoning and the way the emotions play into it, what you say is your armchair speculation about the role of emotions and how they were evolutionarily derived.  I think it's standard fare in evolutionary psychology, and they've got extremely highly developed theories about how all of these social emotions were the result of cooperation dilemmas in hunter- gatherer societies and so forth.

What they don't provide — and the reason that people don't like this field — is that no one can come up with a biological correlate.  And the big argument is not that there wouldn't be a biological correlate to say that certain kinds of moral decision- making are emotionally based, but the real question is where does that emotional response come from?  Is it hardwired genetically or is it socially constructed as a result of experiences that the individual has over birth.  And it seems to me none of the empirical evidence — I mean your kind of implicit assumption is that it's hardwired —

DR. COHEN:  No, no.  Let me correct that right here.  I'm just measuring it.  I have no idea how it got there, whether philogenetically or ontogenetically. 

PROF. FUKUYAMA:  Right.

DR. COHEN:  But with the tools to measure it, we can begin to try and ask those questions.

PROF. FUKUYAMA:  Okay.  But it does seem to me you're awfully far from really having an answer to that because you'd be surprised, even if it were socially learned, it would be very surprising if it didn't light up.

DR. COHEN:  I'm not so sure we're far from answering at least some first- order questions.  For example, not only is it relatively straight forward, but we're actually in the process of beginning crosscultural studies to see whether or not people have different emotional responses to the very same dilemmas, and there's been psychology that addresses this question, but it's been very hard to get hard evidence for the reasons that I said at the beginning.  We can produce harder evidence about that question, and that certainly bears on the question of whether it's learned or it's innate.

PROF. FUKUYAMA:  That kind of crosscultural study could have been done and was done prior to the brain imaging, but I also think that the conclusions you draw about the moral peril we're in is — I would put it quite differently.  What's interesting about that ultimatum game is that it suggests that there's something like an innate sense of human justice; that is to say, people have a certain pride, and they will not accept an unfair division of resources, and they'd rather have nothing rather than have the division of resources be unfair.

That's quite an interesting conclusion —

DR. COHEN:  Why is that?

PROF. FUKUYAMA:  What?

DR. COHEN:  Why is that?

PROF. FUKUYAMA:  Well, I don't know why it is, but if it's a fact that that is actually the result of an evolutionary process which is hardwired, that tells you something interesting about human morality, which is that contrary to the Lockian idea that the mind is a tabula rasa, there actually are innate ideas about justice.  They seem to have come from our evolutionary experience as hunter- gatherers.  But I actually find that reassuring because it means that, in fact, we're not these cold, calculating machines, but we have certain innate principles on which our moral order — and the other one that's cited very typically is a sense of reciprocity, tit for tat.  There's this whole thing comes out of the iterated prisoner's dilemma that would tell you why socially cooperating creatures should develop a principle of reciprocity.

Now the evolutionary psychologists have suggested that that is also a moral principle that is hardwired.  I think it's actually a pretty good one and it is actually reassuring to me that we arrive at that kind of moral reasoning, not through a rational process, a cognitive process, the way the economists posit, but in fact, there are emotions and subrational processes in the human psyche that lead us almost instinctively to those kinds of outcomes.

So I'm not sure that this idea that you've got these evolutionarily- derived impulses that need to be overridden by the super ego that's created only in civilizational time, that that's the fundamental problem.  I think that, in fact, all of our moral structures, including those in advanced civilizations, depend very heavily, fortunately, on the fact that we are wired to have these certain kinds of species- typical responses.  But again, it does seem to me that — well, okay, maybe I'll just —

DR. COHEN:  Obviously, inference is in the eye of the beholder because I look at these data — and again they're early in the game — but I look at them as providing the potential to say look, we can contextualize these quote,unquote moral responses that we have, these intuitions that people seem to have, right, in an understanding of where they came from that may allow us rationally to dismiss them.  And so rather than reify them because we found them, I think, as reasonably, one can say look, now that we understand where they came from and we realize that they're not really what we want, we're free to kind of propose something else, right? 

So it's just the opposite perspective to take the same data, at least as I understand what you were saying.  But the key point is that maybe not the answer we come to, but the fact that the debate is now much more informed.  It's no longer a matter — at some point we'll get to the point, I think, where it's no longer a matter of conjecture as to whether or not people's moral intuitions are informed by their emotional responses which might have either genetically programmed or deeply ingrained cultural roots.  We'll be able to say that.

CHAIRMAN KASS:  Could I jump in on this and jump my place in the queue just because I think it's pertinent here.  It seems to me the issue — and Frank, if I were to come to your aid I would do it this way.  It seems to me the question is not whether this has an evolutionary foundation of the sort that you suggest.  The further question is whether because it is emotionally mediated, it is therefore irrational; or whether or not those emotional responses are the embodiment of a certain kind of reasonableness as opposed to a kind of theoretical rationality.  That would be one way to put it.  And the presumption in a way —   I don't have any difficulty with the findings.  The findings are very exciting to me.  They support my own sense that the attempt to do moral philosophy, as Kant does it, is wrong and that this kind of universalizability is the only measure of rationality.  It might be absolutely reasonable to treat kin better than strangers and that the universalizability of human beings is a construct of theory — by the way, something that we need to think about in the global world, but that you somehow can't say that the abstraction from proximity is going to be an advance if precisely the care for those near and dear depends upon these kinds of rational, these kinds of reasonable things that don't depend upon calculation, but the reasonableness is somehow built into the passions of emotion and love and anger when our own are hurt and things of that sort.

Now that's not to say that those emotions don't cause difficulties and sometimes get the better of what make sense, but I'm not sure I accept the — I don't think that the description of the footbridge versus the trolley dilemma is a sign of moral inconsistency at all.

DR. COHEN:  We differ there.

CHAIRMAN KASS:  But the difference has to do with accepting the view of a kind of calculation of outcome as the measure of reason, whereas the question is how do you describe the moral situation in the first place such that —

DR. COHEN:  Well —

CHAIRMAN KASS:  I don't want to belabor this, but I do think that there are certain kinds of theoretical things that are built into the formulation of the question that produce the dichotomy between what looks to you to be primitive and what looks to you to be advanced and rational, whereas I'm not sure that there isn't a kind of deep reason in what you're calling mere primitive, but it's carried and mediated in a different way.

DR. COHEN:  Fair enough.  So I was, of course, caricaturing the arguments for the sake of clarity, but I think the fundamental point still stands, and I think again it's the inversion of the position that is being laid out between you and Professor Fukuyama, and that is to say that okay, I don't know what the right calculus is, but, at the same time, the fact that we have these intuitions and that we could maybe come to understand where they came from as circumstantially developed and not in the circumstances that we now find ourselves, I agree it doesn't mean that we just therefore dismiss them as primitive and therefore irrelevant, but it does mean that we may have some deeper insight into what their usefulness was and what the limits of their usefulness may now be.

And so the interpretation of the finding is neither that because it's primitive, it's irrelevant, nor that because we have intuitions, as such we should go with them, that that's kind of our moral compass.  It allows us to say no, the compass has to be something else.  And this just contextualizes where those are coming from and allows us, however we might do it — and godspeed to those who are more qualified than I to actually do it — to come up with a theory that is, in some sense rationalist, that takes account of all of our circumstances.  And it can't dismiss love or kin bonding.  Of course not.  That would lead to consequences that would be as deleterious as only caring about your kin, but some balance between the circumstances we currently face and the ones that we've brought with us because, Lord knows, evolution — and this is the peril I'm referring to — evolution is not fast enough to give us the answers.  It got us this far, but something has happened that the answer for which is not evolution, not at the biological or genetic level.

Genetics was able to solve the problems that got us this far, but we now have the capacity to pose problems that genetics is not going to be fast enough to solve.

CHAIRMAN KASS:  Fair enough.  Michael Sandel, please, and then Alfonso is next.

PROF. SANDEL:  Even before we get to the evolutionary biology, my question is prior to that about the logic of the scientific project that you're engaged in and the general question I have is how — what justifies your choice of coding certain responses as emotional as against others?  But in order to get to that, I was puzzled by one thing you said in the talk and then just in this exchange with Leon. 

From your point of view, in order to characterize in the trolley and footbridge case one of the responses, one set of intuitions as emotional, and then you would then go on to explore the neural correlates, it seemed to matter to you that you had run through all the possible rational justifications for answering the footbridge and trolley case differently.  And not having found a persuasive one, that seemed to license calling the response in the footbridge case emotional.  But why, even from your point of view, would that be necessary?  Why can't you just directly, on your own account, characterize the footbridge response as emotional because personal rather than impersonal and so on and code it that way and go ahead and then look for the correlations?  Why was it important — you seemed to suggest it was important and you said we could check on the website — that you had explored all these possible moral justifications for distinguishing and found that they weren't persuasive and therefore — why did you have to go through that?  What would be undermined in the experiment that you did if it turned out that somebody came along with a persuasive moral distinction between those two cases?  Why would that in any way damage the rest of what you've done from your point of view?

DR. COHEN:  Excellent question.  I'm hesitating only because I'm trying to figure out where to begin with the answer.  There's at least or two or maybe three things I want to say in response to that.

First of all, the term "emotion" is a code here.  I mean ultimately words are not the language of science.  It's mathematics and mechanistic understanding.  But until we have that we need some guidance and we need some way of communicating with our colleagues to share the intuitions of what we think the proper mechanism or mechanistic or formal description of the mechanism is, right?

So that's all I think of the word "emotion" as.

PROF. SANDEL:  But you have to pick out certain responses that people give you in order to run the correlation.

DR. COHEN:  I'm going to get to that.  I understand.  In this case, I think what the term "emotion" kind of connotes, if not denotes, is a set of systems that are hardwired to produce rapid evaluations and rapid responses given the exigencies of the feral world in which we grew up.  And so what family resemblance the different systems that we were studying here have to one another is that: they're rapid- interpretation, rapid- fire systems that lead to quick action.  That, to me, is what the mechanistic underpinnings of emotion is and emotion, as we think of it kind of introspectively is just a phenomenological projection or consequence or correlate of the operation of those mechanisms.

Now to answer the kind of the methodological question, in order to get at that as what's accounting for the variance — that is, accounting for the empirical phenomenology here, right? — I have to be certain that there aren't confounds that are alternative accounts.  So for example, supposing it turned out that — and as I've already said I just can't give one problem.  I couldn't give the trolley problem a hundred times because the person would stop paying attention to it after a while.  They'd say, look, I know I hit the left button last time.  I'm just going to hit it again.  They wouldn't be thinking about the problem in the way that engaged the mechanisms I want to study.

PROF. SANDEL:  But even on the trolley and the footbridge problem, if you, tomorrow, discovered there is good moral justification for not pushing and yet for switching, would that cause you to code the behavior differently?

DR. COHEN:  The answer is yes.

PROF. SANDEL:  Why?  Why would it?

DR. COHEN: I don't know what you mean by "code the behavior differently."  It would lead me to worry about the interpretation that I've placed on the data so far, not that I don't anyway, but I would worry more.  That is to say — okay.  Forget about the signal averaging problem and say we could do the experiment with just the trolley and the footbridge problem.

PROF. SANDEL:  Fair enough.

DR. COHEN:  So supposing I hadn't thought of this Kantian alternative, right, with the loop, and I did the experiment, and then Kant came out of the grave and said ha, ha, ha, you fool.  Don't you realize that all that's accounting for that difference is that in one case the person is using instrument, the person is used as an instrument, and what we found were areas of the brain that compute instrumentality. I think that's a silly likelihood or a silly interpretation, but it's a logical interpretation of the data.

Instrumentalism is confounded with emotionality, and what I think subserves emotionality is different than the computation of instrumentality.  I think different mechanisms computer those different functions.  And so now if there's a confound, I don't know how to interpret my data.  So I have to try and construct the experiment in such a way that no other confound, no other reasonable account can be given for why those areas activated in these conditions and not those. 

PROF. SANDEL:  If there were a reasonable account, then —

DR. COHEN:  Then that could provide an alternative explanation and my interpretation of what those brain areas were doing, at least in the context of this experiment, would be only one of at least two.  Now, I don't doubt that that's probably true anyway, but at least that's the game we play when we're playing science, right?  We try and eliminate all the confounds so that the only reasonable account that one can give for the differences is the one that you postulated.

PROF. SANDEL:  Just to test this, could I give — if I have one more minute, to take another set of dilemmas of that kind, that play into this intuition you have about the personal versus the impersonal. 

In the one case you ask people whether in order to — there's an intruder who comes threatening to their home and their family members are there and it's a murderer, let's say.  And you ask people would you be justified in shooting the murderer who is threatening your five children and your wife.  And then you ask them would you stab the intruder?  And it turned out that more people would shoot than would stab, maybe because of the same kind of squeamishness that operates in the footbridge.  And then you offer them a different case where it's not an intruder coming to kill your family, but to steal the hubcaps from your car and you ask would you shoot the intruder — the hubcap thief, and would you stab him?  And there too, more would probably shoot than would stab, though the numbers would be less than in the first case.  Now would — in those cases, which would you code as emotional responses that you would then expect would correlate with the emotional neuro activity in the brain? 

Would it be the stabbing in both cases —

DR. COHEN:  But more so in the intruder.

PROF. SANDEL:  But whether stabbing the intruder was justified in the case of protecting your family, as against stabbing the hubcap thief, would that influence whether you coded the two as emotional rather than rational or rather than morally defensible?

Because in the one case, we assume we would agree that it's possibly — that's it's morally defensible to stab in the first —

DR. COHEN:  Right.

PROF. SANDEL:  And not in the hubcap case.  So what I'm trying to get at is whether what counts as emotional for purposes running the correlations, depends on there being no good moral justification for it or for some more primitive thing that doesn't depend on figuring out whether there's a good moral justification for it.

DR. COHEN:  I don't know the answer to what would actually attain interesting experiment, but if you're asking for my guess, based on how I imagine these systems are operating, it would be that in both cases the same areas would be engaged by the notion of stabbing somebody more than the notion of shooting.

PROF. SANDEL:  So it wouldn't be tied to whether the action is morally justified or not?

DR. COHEN:  No, I don't think these areas are specific.  This is the sense in which —

PROF. SANDEL:  But then it's back to my question.  Why would it worry you if it turned in the case you used if there was a good Kantian or otherwise moral justification —

DR. COHEN:  Because I want to know that their emotional, that these areas are activating for an emotional — representing an emotional process as opposed to an analytic one for lack of a better term, a cognitive one.

PROF. SANDEL:  That begs the question, doesn't it, because we're trying to get at what counts as emotional.  And on one definition it has to do with this primitive idea of proximate versus less proximate, but there's another overlapping consideration that seems to be at work which is morally justified on rational grounds or not, right?

DR. COHEN:  Right.  I'm sorry.  I understand what you're saying now.

We had to start somewhere, right?  We wanted to give ourselves the best shot at getting the results that we expected to get, based on our theory, right?  We couldn't just put people in the scanner and just have them lie there until some event occurred that we hoped would be moral and then see.  We had to create situations, right, that were likely to engage the areas of interest in some way.  We predicted that the way they would be engaged would be according to emotional versus non- emotional circumstances.  We could have done the experiment without moral circumstances at all.  In fact, as I say, the literature has done that.  We wanted to know whether or not emotional areas are engaged in moral circumstances and in some way related to the outcome of more decisions.  But we needed some way of probing that.  So as a bootstrapping problem we said all right, well, how can we construct dilemmas to that they're going to be likely to see this difference, if it exists.  It wasn't guaranteed that it existed, but we wanted to stack the deck in favor of seeing it, if it was there and so it's for that reason that we went through and tried to code these things as personal quote unquote emotional or not.  Just to give ourselves the best chance of seeing those areas activate if, in fact, it was an emotion that explained the differences.

PROF. SANDEL:  I don't want to take up other people's time.

CHAIRMAN KASS:  Alfonso, you want to go ahead?

DR. GÓMEZ-LOBO:  I think, Michael, this is going to go down your lane as well because actually in a way I'm going back to the question I asked of the previous session.  And I'll ask it just again as a matter of perplexity and openness in the following sense.  The experiments to me sound fantastic.  I really enjoy reading all of this data because I think it's very interesting to know the physiological correlates of our emotions.  That's not a new project, of course.  There's been efforts in the past, now not with this level of accuracy and sophistication.  So I find that very welcome. 

And I'm referring to your published papers, the ones that here I can be a bit more accurate with that.  What you do in the first paper is you show that there are neuro correlates to the moral judgments, but of course, this doesn't tell us whether the moral judgments are true or false, right?

And I tend to — if you allow me, I would like to emphasize that because, of course, the question whether they're true or false, again the replies to that question were not going to get by more scans and more MRIs, et cetera.  I think again they depend on other considerations and if I may make a suggestion, for instance, the traditional doctrine of the principle of double effect will give you a lot for the trolley case because the trolley case is set up by utilitarian philosophers.  I mean it's an example that appears over and over in people who believe that the morality of actions has to be decided by outcomes and that's why it sounds as if there were an inconsistency in the foot bridge and in the other example because the outcome is the same, and yet there are remarkable differences, I think, in the two actions.

Now with regard to the Ultimatum Game, again, for me there's something similar.  The Ultimatum Game, I'm not surprised by the outcome because again it's a very old case.  This is described very neatly by Aristotle in The Rhetoric.  It's the case of anger.  Anger is the reaction, the desire of revenge for a perceived injustice.  So for me, the question is well, is it unjust if Dr. Kass offers me $1 for every $9 he gets, I would have to concede that it is just and fair because he does a  lot more work than I do and has much better insights, etcetera.  So in that question, the question of the fairness, the initial question of the fairness again is, it seems to me is not going to be a question we can answer by observing this behavior.

So I'm delighted with the idea of the correlation.  I'd be a little bit more worried if you're talking about causation, in other words, your brain fires up and then you refuse the offer.  It would seem to me that the sequence would have to be that you perceive somehow, you grasp that there's an injustice there which may or may not be true and then, of course, your emotions get fired up.  Isn't there something like that?

DR. COHEN:  I can't tell you the moment at which the injustice is perceived.  Maybe some day we'll be able to do that too, but that experiment hasn't been done.  So I can't tell you the answer to that last question.

I also agree that this study in and of itself nor 10 more like it on their own won't answer the question of whether 9/1 split is just or unjust any more than kind of asking people will.  I think what it may do is reveal where our intuitions about the justice or injustice or in any event our emotional responses to the circumstances come from over the long term.  This experiment alone clearly doesn't do that.  But over the long term a deeper understanding of how these mechanisms work, what are their trigger points, what are the circumstances to which they seem tuned, which ones are not tuned to, will reveal for us where our kind of common sense comes from.  And then — this is kind of the point we've been dancing around all — in this whole discussion is what do you make of that?  Do you decide well that's an important insight — the common sense is a good compass for what's right and just or not.  And that's not for the neuroscientists to decide, but it's certainly going to be — that discussion I think will be contributed to by our understanding of what common sense is.

DR. GÓMEZ-LOBO:  Just as a suggestion, do we need to go back to evolution, why not just to present day understanding say of fairness?  In a democratic society, we expect to get paid more or less the same.

DR. COHEN:  I think there are many determining factors.  I pick evolution because it's a simple and easily described one and because there may be parameters of the processing mechanisms that really are determined by very long standing and old influences, but that doesn't preclude the sort of influence that you describe which I don't doubt for a second is there.

CHAIRMAN KASS:  Folks, we're already a little over.  We'll go a little longer because there are people in the queue and I don't want to short change them, but I have Rebecca, Gil, Mike Gazzaniga and Mike Sandel for a very brief reprise on this and then I'll just have to call it.

Rebecca Dresser, please.

PROF. DRESSER:  I think you've both shown that or you've been provocative in showing us how difficult it is to even sort through the issues and try to figure out what to make of this information, so two of these, your colleague, Dr. Greene, and in a way your first paper, you talk about and you were just saying the use we can put to this knowledge, your colleague talks about moral maturation.  We will inevitably change ourselves in the process and reject some values and retain others and so forth.

I mean part of this whole examination has to be well how good are human beings at putting self- knowledge to use in a beneficial way and sometimes we do and many times we don't.  So I guess that would be something to study as well.

When I was reading a lot of philosophy of mind, I think it was Donald Davidson who said something that stuck with me which was yes, this mind, brain is a physical system and yes, at some level we could reduce it, but it will be like the weather, that is our ability to predict, our ability to control will never be at the level where we ought to make important decisions or construct our lives around that.

So I wonder what you think of that and then in relation to that, some of the possible uses that Dr. Michels was referring to, I was thinking about how would we study these predictive, especially approaches to that you would be able to look at a six- month- old brain, infant's brain and say well, this person looks like she's going to end up a juvenile delinquent so we better do X which would always be probabilistic. 

Now in order to make that judgment you would have had to have a study where you're following all these kids with different kinds of brains and really, if you want to make a lot of these social judgments throughout their lives and then what kind of percentage would be enough to trigger some kind of intervention and then you'd have to do all the studies to show that the interventions were effective, and you'd have to figure out outcomes such as your six month old granddaughter, would it be better if she took ballet or played soccer.  Well, what do you mean better in what respect?  She gets more prizes, she's happier, you're happier. 

So it does seem to me to be a very complex process to think about well how would this then go into actual application and use.  So I just encourage thought about those kinds of questions.

CHAIRMAN KASS:  Thank you.  Gil Meilaender.

PROF. MEILAENDER:  I have a comment and a question.  They would follow- on a lot of other things that have been said.  Just a comment.  It would take way too long to pursue it, but I just can't resist saying, I think there are rational reasons for distinguishing all your versions of the trolley problem from the foot bridge problem.  I mean I don't actually think it's hard to do, in fact.  But the question has to do — I mean you — the structure of the way you move is that you think that certain kinds of decisions that we make are not necessarily good or wise ones.  You suggest that we — once we come to understand their roots, their perhaps usefulness, an earlier time, it will free us to get rid of them.  And it's that that I want to think about.

There's a story about a guy who was driving along, got a flat tire, pulled along the side of the road and turned out he pulled over right next to an institution where emotionally disturbed people stayed.  He gets out.  He jacks up the car and takes the tire off and a resident of the institution is standing there watching him the whole time and then he's put the lugs in the — what do we call it, the hubcap and he accidentally kicks it over and they all roll down in the ditch into the mud and the tall grass and he can't find them.  He's got his tire off and he's standing there looking at it and he just can't figure out what in the world to do.  And the resident of the institution who has been standing there watching all along pipes up and he says you know, I believe if you take one lug off of each of the other three tires and use it to put that tire on, it will serve you just fine until you can get somewhere and get it taken care of.  And the man sort of looks at him with a really astonished look on his face.  He's amazed to get this answer to his problem from this particular source and the resident of the institution says well look, I may be mad, but I'm not crazy. 

We don't know what causes moved him to offer that suggestion, maybe he thinks he's the mechanic for the Queen of England and an expert on these things, but it's a very wise piece of advice.  It's true to the situation.

It seems to me that there's a — the fundamental distinction between causes and reasons needs to be paid attention to here in this work.  Whatever the causes that might lead to certain kinds of behavior, that doesn't in itself tell us whether the behavior is wise, whether it's good, whether it's in accord with the truth.  And it's that kind of fundamental distinction between causes and reasons that it seems to me insofar as you want philosophical payoff from the work.  There are other kinds of payoff that's fine, but if you want philosophical payoff from the work, then one has to get clearer and cleaner on that distinction, that it seems to me so far I can find.

DR. COHEN:  I don't really have anything to add.  I think I agree with you in principle, but — well, maybe — I don't know if I agree with you in principle or not.  I guess —

PROF. MEILAENDER:  I don't think you do.

DR. COHEN:  Maybe I don't.  I would just say that it's not guaranteed that an understanding of cause will lead to reason, but I think it can inform.  I think it's knowledge and knowledge will inform us when we have to make decisions, an understanding of why we do things is one contributing factor, I think, to our decisions about what it is that we do.  It may not be the only one, but it's a useful one.

CHAIRMAN KASS:  Mike?

DR. GAZZANIGA:  It's really a shame that Jim Wilson couldn't be here today.

I just finished — I'm the last one apparently probably on this Council who just finished his book, ten years ago, The Moral Sense, which is a beautiful book.  It slugs through a ton of social science data to come up with a hypothesis that there is a biologic sense of morality and I think the work of Jonathan and his colleague, Josh Greene has really opened up a fantastic opportunity to look at that.

I want to make one question — I'm dying to know your answer to it.  There's a colleague of ours and mutual friend, Mark Reikle, (phonetic) who is talking these days about what brain images mean and to go back to your first point, to bring it back to your own work, Mark Reikle has said when we look at these brain activations and Jonathan was very careful to always use that word, you'll notice, we really don't know if the activation is an excitatory event of the brain area or an inhibitory event.  And so when we start pulling together our models where we're pulling different experiments together and we're speaking of them as activations, when in fact, maybe in one experiment it's an inhibition and in one experiment it's an excitation, how do we actually come to think of these data and the technical of neuroscientists trying to figure out the underlying mechanisms?

DR. COHEN:  I think that's another great question.  I guess I just have to restate what I said at the beginning.  These methods are still really crude and our understanding of exactly what they're telling us about the brain, no less about the mind is still in its infancy and I hope that you take the data that we have published and what I talk about today is kind of more illustrative examples rather than necessarily indications of truth, partly in the spirit of the sorts of uncertainties that Mike points to.

That said, we can guard ourselves against certain sorts of silliness interpretations.  We know — our knowledge about how these measurements reflect neuro activity is growing and as yet most of the assumptions that we've made as they've been addressed by further study, seem to have been right.  That's not to say that at some point we'll find out something really fundamentally wrong with those assumptions, but there's no evidence yet, for example, that when you see a pattern of activity that shows pretty striking similarity in one case to similar patterns of activity in another case that something fundamentally different has happened.  Nobody — in the few studies in which people have gone in and stuck electrodes in and measured blood flow as well as neuro activity, it all kind of lines up.

There are other issues, you know.  What is the rest condition really telling us.  How — those are the things that Mark Reikle has been most concerned with recently.  What is the rest condition tell us, how stable is that?  There's lots more to be learned and no doubt it's going to shape and color future work and our ability to interpret these results, but I've got to say so far it's really pretty impressive how much validation, the findings that have come with these methods has received when it's been done properly from convergent methods.  So that's not a particularly satisfactory answer I know, but —

CHAIRMAN KASS:  Michael Sandel, very briefly.

PROF. SANDEL:  In the Ultimatum Game, I'm playing with Leon.  He offers me $2 and he'll keep $8.  I have two desires in trying to decide whether to accept.  I don't want to forego the $2.  And I don't want to reward greed.  How do you know which of those desires is rational and which is in need of explanation?

DR. COHEN:  Given the circumstances, I think they're both in need of explanation.  I'd like to understand both.

PROF. SANDEL:  Okay.

DR. COHEN:  But what's intriguing about the circumstances created in the laboratory, at least on surface consideration, is that your desire to punish greed doesn't have any immediate consequently value, right?  Now you can say it's reflective of a generic thing that you don't want to turn off in this one case because it's not going to do any good, but I can tell you in any event, for whatever this is worth to you, that in this case it's not going to do you any good.

Now if you think that that's acceptable, then that's fine, then I guess there's nothing more to be explained, but I find that intriguing because I don't think people on average tend to behave in ways that on average is not going to do them good.

And so now we've created at least, immediately a rarified and contorted between what the actual presumably normative goal is and what the behavior is and to me, that is in need of explanation.

PROF. SANDEL:  Suppose you're right about that, then a further part of your claim, this is the ambition, is to say that the emotional desire of the two, namely to punish greed, rather than reap the $2, has certain features in common with the desire not to push the man off the — with the view that it would be immoral to push the guy off the foot bridge.

Now in virtue of what are they the same kind of thing or is it just that they both happen to light up the same part of the brain?  Or is there something —

DR. COHEN:  They don't.  See, this is why I started my response to your initial question with a concern about the use of the word "emotion."  I'm not meaning to lump all things that I probably very sloppily designated as emotional as being the same.  They have a family resemblance, okay?  They're not the same.  So in fact, in the data that I showed you, the insula was the primary area that seemed to predict behavior in the economics task and it was other areas, the posterior cingulate, the anterior gyrus, et cetera, predicted behaviors in the moral reasoning test.  So they're not the same emotional response.  And furthermore, I'll make that claim even more extreme by saying that I think that the desire to reap the $2 is also an emotional response in some sense.  It's a valuative.

So it's just that that is all — that also happens to be more universally rational in that case because the punishment is not reaping any definable goal.

PROF. MEILAENDER:  Other than witnessing to the good of justice in the world.

DR. COHEN:  But that doesn't have any meaning to me, I've got to say, other than that the world will be a better place for that to happen.

PROF. SANDEL:  Does your science depend on this opinion of yours?

DR. COHEN:  I should hope that the science doesn't depend on this opinion.  This hypothesis, I think, does, yes.  But the science doesn't, no.  I mean the same experiment could have been conducted by somebody who believed exactly the opposite, presumably that's the beauty of science, right?  And then the answer will help inform our understanding.

PROF. GEORGE:  But can you be playing what you call the game of science if you presuppose that at least one possibility is we have uncaused behavior, behavior that's rationally motivated, just as such.  It's motivated by his grasp of the value of fairness as an objective intrinsic value.

DR. COHEN:  Obviously, this is — we're back to the same point that will take much longer to have a reasonable discussion about and I hesitate to make a comment in response because I just feel more and more the comments are going to come across as glib and uninformed rather than considered, but I'll do it anyway and say I don't think there is much meaning in science where you can't measure, or at least in principle be able to measure what the outcomes are and the factors are, the causal factors are.

And so I guess the answer in a glib way, right, if I was forced to give a single one word answer would be no.

PROF. GEORGE:  To be clear, I'm not saying that if you were analyzing, if you were doing a moral, philosophical analysis that presupposed that there really were basic reasons for action and rationally motivated action as a possibility, I'm not saying that the philosophical analysis would be science.  It would be something different.

My question is can you play the game of science and believe that there is also this other thing that's not science, that is rational that deals with realities that science can't measure and therefore another discipline has to do the work.

DR. COHEN:  Absolutely.  Anybody is welcome.  It's a totally ecumenical game.  Anybody who believes anything they want can play the game of science.  Those beliefs just don't have much place in the playing of the game of science.  So if you're asking whether you can be a mystic and still be a scientist, sure.  You know?  As I said at the beginning, I personally am agnostic or at least for the purposes of this discussion.  I won't reveal to you what my beliefs are about whether or not there are transcendental realities, okay?  That's my own personal prerogative to believe or not believe.  I am here speaking as a scientist and that's why I won't tell you what I believe about that, okay?

But as a scientist I can tell you that those claims and discussions about those factors just don't factor in.  During the break I was saying, you know, you can't use the doubling cube in Monopoly.

PROF. GEORGE:  But that means there's a possibility that it's not an emotional reaction per se that's motivating the decision in the Ultimatum Game.  It's a reason, but not the kind of thing that's susceptible of scientific explication.

DR. COHEN:  And by that I mean something very strong.  It will never be able to be measured,  use and predicting measurable things.  Now if you're willing to accept that that's the stakes, then yes.  But I want to be clear.  You can't have it both ways.  You can't have that thing out there, influencing measurable things in systematic ways, right and yet it not be physical or somehow be explainable in physical terms, right?

So —

PROF. GEORGE:  Physical meaning causal?  Measurable.

CHAIRMAN KASS:  Could I — the hour is really late and there are two people who want small things, but look, this is a philosophical point that has some scientific purchase.  It's not — I want to change slightly what Robby is saying.

Michael Sandel put very nicely to you the two choices, the desire for the money and the desire to punish Leon, treating them both as in a way equally capable of being formulated cognitively, but both of them carry some kind of a repetitive characteristic.

DR. COHEN:  Absolutely correct.

CHAIRMAN KASS:  Conceding that the line between cognition and emotion is much more blurry than people have hitherto thought and your own contributions to the thinking about morality through this kind of study, I just am delighted to see, but there is an old philosophical teaching which says thought alone moves nothing and that means that any kind of choice is animated not only by some kind of cognition calculation of consequences, but by some kind of desire for the outcome and therefore it would seem that if you went looking for — you might go looking for not just the cognitive aspects of what you call the kind of clear choice because the result is obvious, but you might find other elements of so- called emotional life that are at least as deeply seeded as the root of anger for slight or revulsion at being the one who causes pain to a fellow human being in your face. 

So I guess — I don't want to be tied to the particular remarks, but it does seem to me that the exposure of the multifaceted and perhaps always emotional character or always not simply cognitive character of our choices would produce a much richer kind of anthropology following the lines you've already started and they could be absolutely separate from the kind of moral theory that you and your friend Josh Greene seem to have sort of bought into at the beginning.

I don't think you need that to show us all kinds of really deep and rich things about the way the mind and brain works when we make decisions.  I guess this is partly what Michael Sandel is interested in.  I think it's partly what Robby is interested in.

DR. COHEN:  No, look, first of all, let me say that — let me reiterate what I think I've already said which is I don't think anything about the personal interpretation — the inferences that I've drawn from our data or the theories that led us to these experiments should circumscribe the importance that we're really trying to communicate which is these tools can raise these sorts of discussions and inform — raise these sorts of questions and inform these sorts of discussions.

That said, I feel like I should have the right one last time to defend my view of these, of our findings.  And regret that I use the terms cognitive and emotional because I think that paints way too kind of dichotomous a view of what I think is going on and so in that sense I totally agree with you.  Emotions are coming into play in a sense that emotions reflect motivations, right, and valuative decisions based on evaluation just about everything, if not everything we do has got to be traced to that.

So let me now restate.  I use those terms because — you never quite have the read on your audience and you don't want to speak too highly, you don't want to speak too low and those are accessible terms that people have intuitions of that and at least it got the conversation going.

That said, obviously, that said let me make the more technical point, the way I would be most comfortable making which is that the decision to make — to go for the $2 or the $1, the penny, whatever it is and the decision to punish have essentially qualitatively different statuses in a structure of processing or in the kind of a cognitive architecture as I would imagine it.  And those are describably different okay, and there's a family resemblance, they punish kind of senses of inequity, don't hurt your brethren, than doing utilitarian calculations of what's likely to come in the biggest possible picture that you can calculate.  Those are different, fundamentally different sorts of calculations that require different operations that benefit by different computational architectures or styles of computational architectures that I think are what are going to be reflected in these different brain areas when we really understand what's going on.  We're going to see that they're suited to making different kinds of calculations.  Some are coarse and quick, more deliberate, but accommodating many more degrees of freedom.  That's the more interesting way that I think these things will parse out and the terms cognitive and emotion are just loose descriptions of what those much more detailed and I think formal accounts of what's driving these processes will look like.

That said, I still think there are these family resemblances among the things that evolved earlier, again, evolve is another kind of heuristic or that develop early in life or that are subject to strong cultural influence versus capacities that are less so.

CHAIRMAN KASS:  Paul wants a footnote and we're going to break.

DR. MCHUGH:  Just a footnote.  I liked that last answer.  See if we are on the same wavelength.  When I was taught by my great teacher Wally Nauder (phonetic), he said this is the way to think about the brain.  He said there's the sensory neuron and there's the motor neuron and then there's the big  internuncial net between.  Okay?  And that internuncial net has two elements.  Actually, he said three, but for our purposes, two.  A low- fi and a high- fi system.  The high- fi is the lemniscal system that goes through the thalamus and up to the cortex.  The low- fi up the reticular system and into the limbic system.

And he said the analytic — the great internuncial net is for analytical purposes.  Reason comes from both, okay?  The emotions and drives are in the low- fi.  The perceptions and the details are in the high- fi.  But both are together in trying to make a decision and to ultimately make the right decisions.  And so if you and I are talking, if what you're saying that you don't like the words emotional and cognitive, then you are not trying to drive everything then into the high- fi system.  You're prepared to let the low- fi system give reason and purpose to our decision.  Isn't that right?

DR. COHEN:  Absolutely.  I just want to understand in what sense it's being reasonable.  I'm not saying it's not reasonable at all.  It pays to protect the reputation in some situations.  It pays to not hurt your brethren in some situations.  Don't get me wrong.  I'm not — several people I think have tried to put in my mouth this, the things I'm calling lower order or older  are bad, no.  They're just circumscribed and that's what we can learn.  We can learn something about how they're formulated, what they're good at and by inference thereby, what they're not good at and that's useful and important information.

CHAIRMAN KASS:  Bob Michels has asked for a closing comment.

Mike, this is really the last.

DR. MICHELS:  The last hour, I think, illustrated something that was said between Leon and me jokingly at the beginning about the nonexistence of neuro ethics and later in my comment about the value of neuroscience for your dialogue.  I think the value is that it enriches our understanding of psychology and psychology is critical for your dialogue.  I don't think there's a direct relationship between neuroscience and moral philosophy and I think skipping psychology leads to the kinds of conversations you've had in the last hour.

PROF. SANDEL:  Then we should skip it more often. 

CHAIRMAN KASS:  I want to express the Council's thanks to Bob Michels and Jonathan Cohen for really a wonderful afternoon.  The presentations were illuminating, provocative and I think this has been one of the most interesting conversations this Council has had.

So thanks to both of you.

(Applause.)

Those who are staying for dinner we meet up in the usual room at 6:30 for drinks.  Dinner is at 7.  Eight- thirty tomorrow morning, 8:30, we have guests.

(Whereupon, at 5:48 p.m., the meeting was concluded.)

 

 

 

 


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