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Meeting Transcript
January 16, 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


SESSION 5: TOWARD A "RICHER BIOETHICS"
COUNCIL'S REPORT TO THE PRESIDENT

CHAIRMAN KASS:  Good morning.  We should get started.  This is the fifth session of the meeting devoted toward our project, "Toward a Richer Bioethics," celebrating the release of our — let's call it a report — fourth book, Being Human:  Readings from the President's Council on Bioethics.

This has been a relatively invisible project of the Council in the sense that it has been the subject of no formal Council discussions, though Council members have been consulted at all stages of the process to make suggestions of readings.  And, in fact, some of the readings in this volume have been explicitly discussed.  And probably 10 of the 95 have appeared either in comments made in the meetings or in previous publications.

This is a most unusual document for any government body to produce.  And I think it probably deserves some justification, but I don't want to steal time from the discussion that we are going to have here this morning.  The justification for it is given in the Chairman's introduction to the volume.

And although we are not anything like a congressional committee, if members won't mind, I would like to just insert some of those remarks into the record so they will be part of the official record of this meeting.  The people in the audience have a copy of the text; they can read it for themselves.

I think the Council members know why we care about this subject.  Questions of bioethics very often come to touch the deepest issues of our humanity.  And the readings from the humanities are among the best resources we have for thinking about those things and addressing those questions.

Before turning to the panel, I simply want to acknowledge the extraordinary work of our director of education, Rachel Wildavsky, who collected these essays, who served as the general editor of this volume.  Rachel, we're in your debt for a really, really beautiful project.

(Applause.)

(Chairman Kass asked and received unanimous consent to insert into the record the following prepared remarks, taken from his introduction to Being Human.)

BEING HUMAN:
AN INTRODUCTION

by Leon R. Kass, M.D.
Chairman, President’s Council on Bioethics


Why another thick book about bioethics? Why a bioethics reader? Why a reader on Being Human? And why a reader on being human from the President’s Council on Bioethics? The short answer is this: The Council believes that readings of the sort offered here can contribute to a richer understanding and deeper appreciation of our humanity, necessary for facing the challenges confronting us in a biotechnological age. The longer answer constitutes our introduction to this volume.

We begin at the beginning: What is “bioethics,” and why do we need it? Bioethics is a relatively young area of concern and field of inquiry, less than forty years old in its present incarnation—though many of the questions it leads to are in fact ancient. In the mid-1960s, following the disclosure of several abuses here and abroad, ethical attention first focused on the use of human subjects in medical experimentation. Intense public discussion established the importance of voluntary and informed consent, and institutional arrangements were subsequently developed to protect vulnerable patients against the potentially excessive zeal of otherwise worthy experimenters. Around the same time, it also became clear that advances in biomedical science and technology were raising—and would increasingly raise—more far-reaching and profound challenges to familiar human practices and ways of thinking, feeling, and acting.

By 1970, the effects of the so-called biological revolution were beginning to be felt. Oral contraceptives, tranquilizers, and psychedelic drugs were in use, as were cardiac pacemakers, respirators, and kidney dialysis machines. In vitro fertilization of human egg by human sperm had just been achieved and the first heart transplant had just been performed. People were developing a new “definition of death” that looked to brain activity rather than heartbeat or spontaneous breathing as the definitive sign of existing life. Scientists had discovered a “pleasure center” in the brain, and were exploring possible uses of implanted electrodes in this area for purposes of behavior therapy and control. Genetic screening and pre-natal diagnosis had just arrived, and scientific conferences were being held about coming prospects for gene therapy and even about genetically engineered improvements in the human race. There was great excitement about using the new knowledge and techniques to cure disease, overcome infertility, treat mental illness, and relieve much human suffering. Yet at the same time, people sensed that the new possibilities for intervening into the human body and mind would likely raise large questions, not only about safety and efficacy but also about human freedom and dignity, human self-understanding, and the kind of society we were bringing into being. No one had yet heard of bioethics or bioethicists. But their time had arrived.

Actually, the word “bioethics” was coined in 1970 by the biologist Van Rensselaer Potter—to designate a “new ethics” to be built not on philosophical or religious foundations but on the supposedly more solid ground of modern biology. But the term soon came rather to denote a domain of inquiry that examines the ethical implications of advances in biomedical science and technology for everyday life, as well as for law, social institutions, and public policy. Today, “bioethics” also names a specialized academic discipline, granting degrees in major universities and credentialing its practitioners as professional experts in the field.

Over the past thirty years, the field of bioethics has mushroomed. It has entertained discussions and debates on moral and policy issues connected with abortion, fetal tissue implantation, genetic screening (and privacy and discrimination), assisted reproductive technologies, surrogate motherhood, embryo and stem cell research, cloning, gene therapy and genetic “enhancement,” the use of mechanical hearts or animal organs in transplantation, the use of performance-enhancing drugs in athletics or psychotropic drugs for modifying and controlling behavior, living wills and “Do Not Resuscitate” orders, assisted suicide and euthanasia, and the merits of hospice care—among many, many others. Ongoing attention to research with human subjects has further refined the principles and procedures needed to safeguard subjects’ rights and well-being. Hospital-based ethics committees have been established to deal with difficult end-of-life issues regarding termination of treatment. Professional societies and biotechnology companies employ ethics committees to address specific issues as they arise—say, about whether to practice sex-selection, or how to insure fair access to the fruits of biotechnical innovation. Federal legislation has been enacted both to facilitate organ transplantation and to ban the buying and selling of the organs themselves. Debates continue regarding remedies for the inequities of heath care in the United States or the virtual absence of health care and public health measures in underdeveloped countries abroad. Today, bioethicists teach at most medical schools and universities, advise governments and corporations, and appear frequently in the media. Hardly a day passes without some topic of bioethical significance appearing on the front pages of the newspapers. And the President’s Council on Bioethics is but the latest in a series of national bioethics commissions charged with offering advice about this entire set of developments. Bioethics business is booming, and deservedly so, for there is much of importance at stake.

In creating this Council, President George W. Bush gave us a broad mandate and, among other charges, a somewhat unusual responsibility: “to conduct fundamental inquiry into the human and moral significance of developments in biomedical and behavioral science and technology.” We are also charged “to facilitate a greater understanding of bioethical issues.” Yet, as the Council noted when we first convened in January 2002, many of the deep and broad human implications of the coming age of biotechnology are not today receiving adequate attention. Perhaps it is because the field is so busy attending to the novel problems that emerge almost daily. Perhaps it is because attention to devising guidelines and regulations leaves little time to reflect on the full range of human goods that we should be trying to promote or protect. But it may also be that the concerns and concepts that have come to dominate the discussions of academic and public bioethics, for all their strengths, do not by themselves get to the deepest reaches of our subject.

The major principles of professionalized bioethics, according to the leading textbook in the field, are these: (1) beneficence (or at least “non-maleficence”—in plain English: “do no harm”), (2) respect for persons, and (3) justice. As applied to particular cases, these principles translate mainly into concerns to avoid bodily harm and to do bodily good, to respect patient autonomy and to secure informed consent, and to promote equal access to health care and to provide equal protection against biohazards. So long as no one is hurt, no one’s will is violated, and no one is excluded or discriminated against, there may be little to worry about. Fitting well with our society’s devotion to health, freedom, and equality, this outlook governs much of today’s public bioethical discourse.

Thus, we worry much that human cloning may be unsafe, but little about what it might mean for the relations between the generations should children arise not from the coupling of two but from the replication of one or should procreation come to be seen as manufacture. We worry much about genetic privacy and genetic discrimination, but little about acquiring godlike powers of deciding which genetic defects disqualify one for birth or about how we will regard our own identity should we come to be defined as largely a collection of genes. We worry much about issues of safety or unfairness when athletes use steroids or college students take stimulants, but little about the way these (and other mediating) technologies might distort the character of human activity, severing performance from effort or pleasure from the activity that ordinarily is its foundation. We worry much about the obstacles to living longer, but little about the relation between trying to live longer and living well.

In a word, we are quick to notice dangers to life, threats to freedom, and risks of discrimination or exploitation. But we are slow to think about the need to uphold human dignity and the many ways of doing and feeling and being in the world that make human life rich, deep, and fulfilling. Indeed, it sometimes seems as though our views of the meaning of our humanity have been so transformed by the technological approach to the world that we may be in danger of forgetting what we have to lose, humanly speaking.

To enlarge our vision and deepen our understanding, we need to focus not only on the astonishing new technologies but also on those (in truth, equally astonishing) aspects of “being human” on which the technologies impinge and which they may serve or threaten. For bioethical dilemmas, though generated by novel developments in biomedical science and technology, are not themselves scientific or technological matters. They are human dilemmas—individual, familial, social, political, and spiritual—confronted by human beings at various stages in the human lifespan, embedded in networks of meaning and relation, and informed by varying opinions and beliefs about better and worse, right and wrong, and how we are to live. Often, competing human goods are at stake (for example, seeking cures for disease versus respecting nascent life); in other cases, the evils we seek to avoid are deeply intertwined with the goods we ardently pursue (for example, eliminating genetic defects without stigmatizing those who have them). Moreover, both in practice and in our self-understanding, bioethical issues generally touch matters close to the core of our humanity: birth and death, body and mind, sickness and health, sex and procreation, love and family, identity and individuality, freedom and dignity, aspiration and contentment, the purposes of knowledge, the aim of technology, the meaning of suffering, the quest for meaning. A richer bioethics would attend to these matters directly and keep them central to all bioethical inquiry and judgment. A richer bioethics would feature careful and wisdom-seeking reflection regarding the full range of human goods at stake in bioethical dilemmas.

In all of its work to date, the President’s Council on Bioethics has tried to practice and foster such an approach. For the Council, “bioethics” is not an ethics based on biology, but an ethics in the service of bios—of a life lived humanly, a course of life lived not merely physiologically, but also mentally, socially, culturally, politically, and spiritually. Even as we have tackled specific issues such as human cloning or the uses of biotechnology that lie “beyond therapy,” we have sought to probe the meanings of the intersections of biology and biography, where life as lived experientially encounters the results of life studied scientifically. We have sought as best we can to clarify, promote, and defend “being human.”

Where might we seek help in thinking about “life lived humanly,” about birth and death, freedom and dignity, the meaning of suffering, or any of the other marks of a genuinely human experience? Since the beginnings of human self-consciousness, these matters have been the subjects of humanistic reflection and writing, capturing the attentions of great thinkers and authors. Works of history, philosophy, poetry, imaginative literature, and religious meditation have pondered and commented upon—and continue to ponder and comment upon—these matters. In the Council’s own discussions and reports, we have on several occasions looked to these works for their insights and instruction (roughly a dozen of the works included in this volume have explicitly entered the conversations at our meetings or the pages of our writings). And each of us individually, explicitly or tacitly, relies on what we have learned throughout our lives from texts such as these, as we grapple with the difficult bioethical issues before us. Early recognizing the value of such readings, we have featured many selections “From Our Bookshelf” on the Council’s website (www.bioethics.gov). Now, “to facilitate a greater understanding of bioethical issues,” we have collected and organized them in this volume in the hope that others may discover for themselves the help that is available from wise, sensitive, and thoughtful authors, many of whom come from other times and places. As we strive to stay human in the age of biotechnology in ever-better and fuller ways, we must take whatever help we can get in deepening our appreciation of “being human.”

We do not offer these readings as authoritative or as authorities. As readers will discover, they differ too much among themselves to constitute any single coherent teaching. Rather, we offer them in the wisdom-seeking—rather than wisdom-delivering—spirit, as writings that make us think, that challenge our unexamined opinions, expand our sympathies, elevate our gaze, and illuminate important aspects of our lives that we have insufficiently understood or appreciated.

Each reading is accompanied by a brief introduction directing readers toward the bioethical implications of the text, not by drawing conclusions but by asking questions. As any teacher knows, most good books do not teach themselves. We are all frequently lazy readers, who pass off what is puzzling or unfamiliar, and, even worse, who fail to see the depth in what is, by contrast, familiar and congenial. Often our prejudices get in the way. Sometimes, our inexperience blinds us to crucial subtleties and nuances. Accordingly, we have prefaced each reading with some observations and questions designed to make for more active and discerning reading. These questions should be suitable for discussion by groups reading together or for study by individuals reading alone. In some cases, where the text seemed more remote or where we thought it helpful, we have taken a more didactic tone, asking the reader to come at the text with certain questions and concerns in mind. We have done this with mixed feelings; we do not wish to get between author and reader, nor do we wish to imperil understanding of texts written by subtler and greater minds because of our limited understandings and specialized concerns. We thus encourage the readers to use the introductions if they find them helpful, but to treat them with the proverbial grain of salt.

Readers will note, though, that in our choice of readings we have not excluded texts that evince strong moral viewpoints or that are rooted in particular religious faiths. We have welcomed all valuable anthropological or moral insights, regardless of whether they are rooted in religious faith, philosophy, or ordinary personal experience. Respect for American pluralism does not mean excluding deeply held religious (or non-religious) viewpoints or sensibilities. On the contrary, with the deepest human questions on the table, we should be eager to avail ourselves of the wisdom contained in all the great religious, literary, and philosophical traditions.

One of the virtues of an anthology is that readers are free to pick and choose what they wish to read, skipping around in no particular order. Yet, as we will now indicate—and as the introductions to each of the chapters will make even clearer—there is method in our ordering, and we think there is additional advantage in following the text straight through.

It remains, therefore, only to sketch the structure of this volume. The (ninety-five) readings are divided into ten chapters; each chapter opens with a brief introduction, setting forth the topic at hand and providing a synoptic view of the readings that follow. The ten chapters are in turn arranged in three sections.

The first section, “Natural Imperfection and Human Longing,” introduces a central human question that lurks beneath the surface of many bioethical issues: Which is the proper human attitude or disposition in the world: molding or beholding? When and to what extent should we strive to change and alter nature and especially our own given nature, in an effort to improve or save it? When and to what extent should we strive to accept and appreciate nature and our own given nature, in an effort to know or savor it? This section, comprising three chapters, also introduces the means we have for acting upon these dueling impulses and longings: biomedical science and the art of medicine, both major players in the dramas of bioethics today.

In Chapter One, “The Search for Perfection,” readings explore the age-old human aspiration to improve our native lot, removing our imperfections and bringing our nature closer to our ideal. Does our flourishing depend on our ability to better our form and function? Or does it depend, conversely, on our ability to accept and even celebrate our natural limitations?

In Chapter Two, “Scientific Aspirations,” readings from biographies and memoirs of great scientists explore the motives and goals of scientific activity. Both as a mode of inquiry and as a body of knowledge, science has served both human aspirations—beholding and molding—although its utility as the basis of technological innovation is one of the central features of modern science. Yet science is also a human—and ethical—activity, the fulfillment of personal human desires. How do scientists themselves see the relation between theory and practice? What guides their own scientific quest?

In Chapter Three, “To Heal Sometimes, To Comfort Always,” we turn from the pursuit of knowledge to the age-old medical dream: by means of such knowledge, to bring healing to the sick and wholeness to the broken, and, in the limit, to perfect our vulnerable and mortal human bodies. Readings explore the purposes of medicine, seen from the perspective of doctor and patient, and examine a vocation not only to heal but also to care and comfort.

The second section, “The Human Being and the Life Cycle,” moves from aspirations of and for human beings to questions about human nature itself: What is a human being? And what sort of a life have we human beings been given to live? The four chapters comprising this section treat various aspects of these anthropological questions, many of them sorely neglected in much current bioethical discourse: the meaning for our identity of our embodiment; the tension between change and stability as we progress through the life cycle; the place of begetting and belonging in human flourishing, as we live with ancestors and descendants; and the meaning of mortality as the ultimate boundary of any human life. The relevance of these topics to contemporary bioethical arenas such as organ transplantation, assisted reproduction and genetic screening, and research to alter aging and the human lifespan needs only to be mentioned to be seen.

In Chapter Four, “Are We Our Bodies?” readings explore the puzzling question about the relation between our bodies and our minds (or souls). Are we mostly one or the other? Are we rather only the two of them together? How are our lofty aspirations related to our “fleshiness”? How crucial is our body to our identity and worth?

In Chapter Five, “Many Stages, One Life,” readings ponder what it means that we live in time, that we both change constantly yet continue always as “ourselves.” Is there a shape or meaning to our temporal journey? What sense are we supposed to make of life’s various “stages”? What unites the beginning of our lives with its end?

In Chapter Six, “Among the Generations,” we move from the life cycle of individuals to their connections to those who came before and those who come after. Readings explore the experience and significance of human procreation and renewal, as well as our obligations to ancestors and descendants. How important are biological ties to the work of human parenting and perpetuation? What is the significance of the family tree? What do the various branches owe to one another?

In Chapter Seven, “Why Not Immortality?” we move from procreation to a more radical response to our finitude: the quest for personal immortality. The readings consider various expressions of, and responses to, this ancient human longing. How does this longing affect the way we spend the time of our lives? What does it imply regarding the goodness of terrestrial life? Is mortality only a burden or also a blessing? Does the answer depend on the truth about an afterlife? Would our longing for immortality be satisfied by having “more of the same”? Do we long for an endless existence or for a perfected one?

The third section, “Cures, Improvements, and Their Costs: Virtues for a Richer Bioethics,” moves from the anthropological questions to the ethical and spiritual ones, with a special eye on possible excellences that may be enhanced or threatened in the age of biotechnology. The three chapters in this section deal with some of the deepest bioethical questions: the value, if any, of vulnerability and suffering; the importance, for living well, of unmediated and direct engagement with the world and with our fellow creatures; and the character of human dignity. Once again, these are matters that tend to be neglected in current bioethical discussions. Yet on reflection, their centrality is not difficult to recognize, especially in such matters as our use of heroic measures to save and extend life, our increased reliance on psychotropic drugs to handle the trials and tribulations of life, or our attempts to describe and explain human life and human freedom solely in terms of genes, hormones, or neurotransmitters.

In Chapter Eight, “Vulnerability and Suffering,” the readings consider the venerable question of why we suffer, and the further question of whether there is anything to be said on suffering’s behalf. Would eliminating all suffering be humanly desirable? Could it be that some forms of suffering are essential to our identities and our dignity? Or is this just a rationalizing effort, to make—quite literally—a virtue out of necessity?

In Chapter Nine, “Living Immediately,” the readings look closely at the character of human activities when these are engaged in at their peak. Of special interest are instances when we can be at-work in the world wholeheartedly and immediately, unencumbered by pain and suffering and not deflected by technological or other “intermediaries.” How can we take advantage of the powers technology bestows on us without hazarding distortions of the very activities these powers are meant to serve? What is required for genuine encounters with the world and with other people—for what some call “real life”—and what are the obstacles to their achievement?

Finally, in Chapter Ten, “Human Dignity,” we turn explicitly to the theme that has been tacitly present throughout the volume: the dignity or worth or standing of the human creature. Though the term, “human dignity,” has a lofty ring, its content is quite difficult to define. Or rather, to be more precise, many different authors and traditions define it differently, as the readings in this chapter make abundantly clear. Yet they are all struggling to reveal that elusive core of our humanity, those special qualities that make us more than beasts yet less than gods, the encouragement and defense of which may be said, arguably, to be the highest mission of a richer bioethics. Some readings will do so by argument, others by presenting instances and exemplars. Taken together, they should help us see the profoundly special character of human beings and the special virtue to which we may rise—with and without the help of biotechnology.

 

End of Chairman Kass's inserted remarks.

CHAIRMAN KASS:  To celebrate the release of this volume but also to subject our enterprise to some critical scrutiny, we have convened a really wonderful panel this morning to discuss with us the role of the humanities in bioethics.

We have, first of all, Professor Bruce Cole, distinguished art historian specializing in the Renaissance, with a keen eye for being human, who is now the eloquent Chairman of the National Endowment for the Humanities, the country's leading voice on the importance of the humanities for our general culture.

We have Professor Paul Cantor from the University of Virginia, a long and distinguished career as a teacher of literature who almost 20 years ago, I believe, did a book on the creator and creature on the romantic myths, including the discussion of Frankenstein.

Then we have Dr. Edmund Pellegrino, who is now Professor emeritus of medicine and medical ethics at the Center for Clinical Bioethics at Georgetown University School of Medicine.  I think it is fair to say that Ed Pellegrino has, for more than 50 years, been the most visible and most eloquent exemplar of the medical humanities in this country and a pioneer in this field.

Welcome to all three of you.  We're simply delighted that you would come and join us on this occasion.  And we look forward to your remarks.  We will go in that order after the presentations.  We will have either discussions amongst the panelists themselves or involving all of us.  Thank you.

And please, Bruce, would you like to start?

DR. COLE:  Thank you, Leon.

PANEL DISCUSSION: THE ROLE OF THE HUMANITIES IN BIOETHICS

DR. COLE:  It's an honor to be here and a pleasure to address this group on such an important occasion.  You began your discussions two years ago not with an assessment of the latest technology, a list of medical possibilities, or a survey of the policy together with a story.

Nathaniel Hawthorne's short story "The Birth- mark" illustrates both the timelessness and the dangers of the pursuit of human perfection and the revolt against limitations.  More than that, it shows how the stories, poems, philosophy, and thought of the past have something to say about our future dilemmas.  I think it also shows the unique and thoughtful approach of this Commission headed by my friend and colleague Leon Kass.

I want to thank Leon for inviting me here today and for the opportunity to speak to issues I believe are inextricably linked with the humanities.  I also want to thank Dean Clancy and the Commission staff for their work in making this meeting possible.  And I would like to congratulate all of the members of the White House Bioethics Commission on the release of your book, Being Human.

The National Endowment for the Humanities has sponsored numerous projects seeking to broaden understanding of these issues.  In the past four years alone, the NEH has spent over a million dollars on projects to extend bioethics research, establish endowments for bioethics study, and create fellowships and underwrite documentary films, studies, and even textbooks.

The NEH funded the Baylor College of Medicine's work, A History of Medical Ethics, a one- volume history of medical ethics from antiquity to the twentieth century.  It also provided special support for the Encyclopedia of Bioethics, the standard reference work in the field.  But today we are here to celebrate this Commission's new book.

Being Human accomplishes something important.  It sheds light on bioethics through the lens of the humanities.  To quote one insightful passage of the introduction, "We need to focus not only on the astonishing new technologies but also on those aspects of being human on which the technologies impinge.  For bioethical dilemmas, though generated by novel developments in the biomedical science and technology, are not scientific or technological matters.  They are human dilemmas, individual, familial, social, political, and spiritual, confronted by human beings at various stages of the human life span embedded in networks of meaning and relations and informed by varying opinions and beliefs about better or worse, right or wrong, and how we are to live," unquote.

Over the last several years, the argument that the realm of bioethics is the province of the medical field and technology industry appears to be gaining ground, not because it has been persuasive but because it has been assumed.

The advent of new technologies has been almost universally celebrated.  And questions about where those technologies may lead us have often been written off as irrational fears of Luddites or practitioners of an exotic faith.  Of course, advances in human knowledge are grounds for excitement, but such excitement only increases the need for a dispassionate consideration of where the applications of such knowledge takes us.

A purely medical or technical response is not a complete one.  It is all too easy to disregard the categorical imperative and assume a technological one.  I think it is fair to say that the allure of the technological imperative is particularly strong in our time and, as a result, the dangers of dehumanization more stark than ever.

New technologies are tools which can be used to help or harm, edify, or demean, protect, or destroy.  A knife can be used to perform life- saving surgery or murder.  New biotechnologies have the potential to do far more than merely save or end a life.

Cloning creates a new life in the form of a carbon copy.  Genetic advances hold out hope for designing our offspring according to our wish and promises to redefine what it means to be human.

The new discoveries and knowledge undergirding these technologies hold out promise and hope of curing disease, overcoming disability, and even extending life, but they also contain great dangers, the commodification of people, the reduction of human life to disposable resource, nor is this a distant danger, repellent as it is.  It requires that we take stock before taking action.  As Leon has said, there is often wisdom in repugnance.

President Bush charged this Council to "conduct fundamental inquiry into the human and moral significance of developments in biomedical and behavioral science and technology."  His instructions assumed that the ultimate significance of biotechnology was broader and deeper than its utility and that such an inquiry must include those outside the technology industry.  Without such an inquiry, we stand in danger of ambling blithely but blindly into a brave new world.  Ultimately, this inquiry is incomplete without the humanities.

The humanities are, quite simply, the study of what it means to be human.  The legacy of our past, the ideas and principles that motivate us, and the eternal questions that we still ponder, the classics and archaeology show us from whence our civilization came.

The study of literature and art shapes our sense of beauty.  And the knowledge of philosophy and religion gives meaning to our sense of justice and goodness.  At their core, issues of life and death, identity and connectedness, aspiration and limits, healing and death all pertain to what it means to be human and, thus, are questions for the humanities.

Not only do the humanities have profound implications for bioethics, but the reverse is true as well.  Many of the new technologies you discuss have the potential to fundamentally redefine what it means to be human.  Germ line manipulations, genetic engineering, and other procedures would alter DNA and human character.  It is hardly an exaggeration to say that the future of humanity has some implications for the future of the humanities.  We're all in this together.

I would like to make one last point.  As many of you know, I am an art historian by background and training.  I hope you forgive a plug for including great works of visual arts — I can't give any remarks without mentioning art; I'm sorry — in the survey of sources you consult in your studies here.

Before we had evidence of the written word, we had cave paintings.  There are millennias' worth of evidence that the instinct and drive to make art is a human universal, transcending time, place, culture, religion, language, and ethnicity.  Many of the great masterpieces in the history of art deal directly with issues you grapple with here:  human origins, dignity, death, limitations, and desire for perfection.

One of the great advantages of art is that it concretizes the abstract and gives it physical shape.  It provides a new and powerful way of looking at and learning from the wisdom of the ages.

This Commission has a difficult task.  I commend and congratulate it for its exceptional work and readiness to draw deeply from the humanities in delving into the perplexing dilemmas of biotechnology.

In a time when many are tempted or pressured to resolve bioethics questions by reference to market pressure or interest groups, it is essential for thoughtful citizens to consider the full implications of new technologies and knowledge.  Both the arts and the humanities give us a way to approach these great issues.  No inquiry worth the name is complete without them.

Thank you.

(Applause.)

CHAIRMAN KASS:  Thank you very much.

Paul Cantor?

DR. CANTOR:  It is a pleasure to be here this morning.  It is especially a pleasure to celebrate the publication of this wonderful anthology, extraordinary event.  I think the last time a government body produced an anthology of literature, it was under the orders of the Emperor Augustus.

So I'll sum up the importance of the humanities for the study of bioethics by saying science can tell us how to do things, but it can't tell us whether to do things.  And that's where the humanities come in.

The humanities help us to imagine the consequences of what we are doing with science.  This anthology is very good in raising the issue of immortality, for example.  The ultimate promise of modern science is immortality.  That's why it gets the big bucks when it comes to funding.

But literature can help us imagine what immortality might really be like and in the case of the Swift, Jonathan Swift, excerpt you have here, show that there might be a down side to the seemingly wonderful prospect of living forever.  And so that I think has been the great function of literature, the humanities in general.

I really applaud this anthology.  It has an extraordinarily wide range of selections.  That's one of its best features, I think.  There are some of the obviously great and profound authors, like Homer and Tolstoy, but I was very pleased to see an excerpt from Gattaca, from a film, reminding us that literature doesn't just cease with the printed word.  And that film, representative of the whole genre, really is one of the ways that helps us do this imagining.  I would have put Blade Runner in the book if I had had a choice.

Another wonderful selection was the one from J. M. Barrie on Peter Pan.  It made me go back and reread the original play.  I hadn't realized how serious it was in its own way.  Indeed, I now think there is no better way of confronting the problem of what it is to grow up and what the choices are between staying an eternal child, which many of us might like to do, and then facing responsibilities of adulthood.

So I think this anthology has a great deal to offer.  The selections were very well chosen.  And I hope it gets widely disseminated and people can draw upon it.

To pursue this question of the relation of the humanities to bioethics, I would like to concentrate on a period that I specialize in, the Romantic period, the early Nineteenth Century, say a few remarks about that because, in a way, this was the first period that confronted modern science and modern technology.  These are the first writers, around 1800, who are dealing with the beginnings of the Industrial Revolution.

They help us raise one question about turning to the humanities, a point that I think a lot of scientists might raise.  That is, who are these poets, who are these people, the humanities, to say anything about science?  We worry that they don't know anything about science.  And can they have anything reasonable to say if they argue?

Moreover, there is a kind of occupational tension between poets and scientists.  I'll talk about that in a few minutes.  There is a sense in which poets in the Nineteenth Century felt themselves being crowded out by science.  And maybe if they say warning things about the direction science is taking us, it's out of a kind of professional envy.

Well, I think if we actually look at this period in question, it turns out that a number of the Romantic poets and other writers of the time actually were quite knowledgeable about science.

We have the standard view that the Romantics were anti- technology — and to a large extent, they were — and that they were anti- science.  But, in fact, they were the first people to realize the imaginative possibilities of science.  It's no accident that, in effect, the first work of science fiction, Frankenstein, which I will speak about in a minute, grows out of this period, but even someone like Wordsworth was impressed by science.

I am going to read you a little sonnet he wrote called "Steamboats, Viaducts and Railways."  Now, we normally think about Wordsworth writing about daffodils, but he actually could get pretty turned on by railways as well. "Motions and Means, on land and sea at war with old poetic feeling, not for this, shall ye, by Poets even, be judged amiss."  As he starts off there, he knows that these new technologies are somehow at war with poetry, but he's not going to judge them negatively for that reason, "Nor shall your presence, howsoever it mar the loveliness of Nature, prove a bar to the Mind's gaining that prophetic sense of future change, that point of vision, whence may be discovered what in soul ye are.  In spite of all that beauty may disown in your harsh features, Nature doth embrace her lawful offspring in Man's art; and Time, pleased with your triumphs over his brother Space, accepts from your bold hands the proffered crown of hope, and smiles on you with cheer sublime."

"Sublime" was in a way the master word of the whole Romantic generation.  Again, we normally think of Wordsworth thinking of the great mountains of the Lake District as being sublime.  But here he can look at steamboats, viaducts, and railways and think of them as sublime.

And as the wave of the future, you see here that, in fact, this Romantic generation was quite impressed with the new possibilities of modern technology.  I bring that up just so that when they criticize it, we can say it wasn't simply out of ignorance or a kind of reactionary spirit.

Percy Shelley and Lord Byron are another example of Romantic poets who were quite knowledgeable about modern science, who were studying contemporary geology and biology and very much fired up and inspired by the new imaginative prospects raised by modern science and modern technology.

Nevertheless, this generation did put up a number of red flags of caution.  The greatest example of that is Mary Shelley's Frankenstein.  I want to speak about that.  I see, you know, the volume begins with "The Birth- mark."  "The Birth- mark" would not have been possible without Frankenstein, one of the works that inspired it.

Since you did discuss "The Birth- mark," I just want to show you that literary critics do have something to say I hope you noticed with the character Aminadab, spelled backwards, his name is bad anima, bad.  So I think that's a little clue to what is going on in that work.

Anyway, I really think you should have included Frankenstein somehow in this volume.  That's my one criticism.  It actually has gone on to become in the popular imagination the great example of a warning against the dangers of modern technology.

Most people know the story through the movie and are unaware of how literate the book is.  So I am going to read a couple of passages from this, which really show how prophetic Mary Shelley was in questioning some of the consequences of scientific enterprise set loose without caution.

This is from the chapter where Victor Frankenstein is recounting his original planning of his creature.  Unfortunately, this displays a great deal of insight into sometimes the lack of planning in scientific procedures.

This is what Victor says, "I doubted at first whether I should attempt the creation of a being like myself or one of simpler organization."  In other words, should he have started with a small project or go straight for creating human life?  Here he says, "But my imagination was too much exalted by my first success to permit me to doubt of my ability to give life to an animal as complex and wonderful as man.  The materials at present within my command hardly appeared adequate to so arduous an undertaking, but I doubted not that I should ultimately succeed.  I prepared myself for a multitude of reverses.  My operations might be incessantly baffled and, at last, my work be imperfect.  Yet, when I considered the improvement which every day takes place in science and mechanics, I was encouraged to hope my present attempts would at least lay the foundations of future successes.  Nor could I consider the magnitude and complexity of my plan as any argument of its impracticability.  It was with these feelings that I began the creation of a human being.  As the minuteness of the parts formed a great hindrance to my speed, I resolved, contrary to my first intention, to make a being of a gigantic stature; that is to say, about eight feet in height, and proportionably large."

Now, those last lines have the distinction of being quoted in Mel Brooks' Young Frankenstein, but they also sum up Mary Shelley's critique of Victor Frankenstein, "As the minuteness of the parts formed a great hindrance to my speed, I resolved, contrary to my first intention, to make the being of a gigantic stature; that is to say, about eight feet in height."

Now, here Victor does not consider the consequences for the creature of its being eight feet in height.  He's got a problem.  He can't find miniature parts.  He's in a real hurry.  So he scraps the original plan and says, "Well, I'll make it eight feet tall."  In some ways, all the problems that this poor creature has follow from this last- minute revision of the plans.

Any time scientists tell us, "Well, don't worry about the consequences.  We've just got to get this project underway.  It's really important to do it quickly.  We have to use what we have," I think this passage from Frankenstein should be read to them.

Moreover, it goes on to say, "Life and death appeared to be ideal bounds, which I should first break through, and pour a torrent of light into our dark world."  That again I think very well captures the spirit of modern science that any limits to human endeavor are merely ideal bounds.  And the great goal is to break through them.

And then, even more tellingly, Victor says, "A new speciess would bless me as its creator and source; many happy and excellent natures would owe their being to me.  No father could claim the gratitude of his child so completely as I should deserve theirs."  Now, why can no other father ever claim such gratitude?  Well, every other father somehow needed the help of a mother to produce a human being up until Victor Frankenstein's process here.

Here I think, as Shelley brilliantly focuses in on the will to power behind modern science, "A new speciess would bless me as its creator; many happy and excellent natures would owe their being to me," and then that desire to have the complete gratitude here.  It's interesting that Mary Shelley as a woman identified this masculine aspect of Victor Frankenstein's science that fundamentally he was turning against natural means of reproduction in order to be able to do something that he could get all the credit for himself.

Again, I think Frankenstein is a marvelous work for seeing the contribution the humanities can make to our understanding of these sorts of issues of bioethics.

Again, Mary Shelley's husband, Percy, was quite knowledgeable in science.  He almost blew up his room at Oxford with chemistry experiments.  People have said, Alfred North Whitehead I think was the one who said, that if Shelley had gone into chemistry, he would have been a genius, "a Newton among chemists," I think was his phrase.

So, again, Mary Shelley was not ignorant of science.  In fact, this work was way ahead of the science of her day.  She had studied a bit about Galvani and his battery experiments.  That was all part of the background to Victor Frankenstein.

But what she is able to do is imagine what the consequences would be to a being who was created this way.  That is the failure she shows on the part of Victor Frankenstein.  He is thinking only as the creator here.  He is thinking only of what will redound to his own glory.  That means doing things quickly and doing them immediately and with what is at hand.

He is not thinking through what it would feel like to be eight feet tall.  Remember, this is in a world with people who are mostly five feet tall and before the time of the NBA.  So the eight feet was not in any way going to be an advantage to this creature.

I am going to end now with a quote from Mary Shelley's husband, Percy Shelley, who wrote a marvelous essay called The Defense of Poetry, which, again, I really recommend to you.

The circumstances of its origin are relevant.  A man named Thomas Love Peacock had written an essay called The Four Ages of Poetry, in which he basically argued that science had made poetry obsolete in the Nineteenth Century, that science now had demythologized the world.  It was fine for Homer to write poetry when people believed in all of these Olympian gods, but he said something like, "How can you expect to find a water nymph in Regent's Canal today?  We don't believe these myths anymore."  He basically wrote an essay that obviously was very upsetting to early Nineteenth Century poets because he was trying to tell them that science had put them out of business.

Well, Shelley wrote a very eloquent and profound defense of poetry, as he calls it, which actually is one of the best statements on the relevance of the humanities to science because he does try to make this point that poetry can imagine what science cannot.

I will just end by a quotation from Shelley where he tries to tell us what poetry can do for science.  We are to "imagine that which we know; we want the generous impulse to act that which we imagine; we want the poetry of life; our calculations have outrun conception; we have eaten more than we can digest.  The cultivation of those sciences which have enlarged the limits of the empire of man over the external world has for want of the poetical faculty proportionally circumscribed those of the internal world, and man, having enslaved the elements, remains himself a slave."

In some ways, I can think of no better characterization of the current state of modern science, "our calculations have outrun conception."  I can think of no better warning than that "having enslaved the elements," man now "remains himself a slave."

(Applause.)

DR. PELLEGRINO:  Good morning.  Like my fellow participants, I am pleased to be with you, but I suffer under two particular encumbrances.  First, I am here because Richard Selzer has been ill.  And I stand, therefore, in the place of someone I could not possibly emulate, who is himself a personification of how literature and ethics come together in his own person and in his eloquent writing, too.

The second impediment is that as you look around the table, I am reminded of a story, which you probably know but I think is apposite sufficiently here for me to repeat it.  And that is a story of the man who went to heaven at a time when in heaven there was a requirement, as there has been for those who occupy chairs in universities, for an inaugural speech.  An inaugural speech could be on any topic the soul would like to address.  The man from Johnstown said, "I would like to talk about the Johnstown Flood."

St. Peter said, "Well, we are very liberal here.  We will allow you to talk about anything you want, but let me warn you Noah will be in the audience."

As I look around this table, I see clones of bioethical Noahs, friends of mine, sometimes colleagues, sometimes debating friends.  I am very, very much reticent to try to say much of anything in the presence of people who know so much more than I do about it.

My only advantage, as Leon said, was having been at this a long time.  So I will be saying something about paleoethics and hopefully bringing it up to something somewhat more contemporary.

What I have in mind is the following.  First, I would like to make a few quick comments about how much I applaud this effort of the Council and particularly in its latest volume.  The stories put forth there, the narratives, literature, are extremely useful and helpful and apposite in bringing the facts clearly to all of us with moral questions, moral problems, moral decisions.  All of them are unique and personal and embedded existentially in the lives of individual human beings.

That is something which is just beginning to be emphasized, although it has been known for a long time in the world of literature.  If you go back to the ending of The Iliad and the ending of The Aeneid, you find the tremendous moral challenge of what a victor does with the one he has vanquished.  On the one hand, in The Iliad, we have an example of mercy, respect for tradition, and the sparing of the enemy.  And in The Aeneid, we have the opposite:  the absolute application of what the hero thinks is justice.

So let me start then on the collection of the one or two points I want to make in the brief time allowed for me.  The collection itself illustrates beautifully, as I said, the enfleshment of moral issues and problems.

Note, though, that at the introduction of each of these episodes, there is a series of penetrating questions.  Those penetrating questions are questions which cannot be asked by returning to the story.  They are philosophical questions.  They illustrate beautiful what Italo Calvino said, that the point in the terrain at which literature and philosophy — read ethics at this point — meet is at ethics.

What I would like to do, then, is make three brief observations on the interaction between ethics and not just literature, but the humanities in general.  I do so under the rubric of the enrichment of bioethics, which is one of the aims, I gather, of this particular volume and I think a worthy one.

First, a quick historical look.  You couldn't avoid that with someone at my advanced age.  I will not give you anecdotes of my personal involvement.  So relax.

Second, a word about the central paradox, central ethical paradox that must be faced and which I think the Council has opened up.  I would venture to say that if the Council can pursue this question further and already has I think made a great contribution, your greatest contribution probably would be if you could advance this notion of the enrichment of bioethics because the questions that you deal with and we deal with are questions for the entire public.

What eventually must be faced is the enrichment of bioethics and the question which is running through the remarks my fellow participants have already made, what is it to be human?  A central fundamental question of philosophical anthropology or theological anthropology, what is man, what is woman, what is our purpose, what is our destiny?  And all of the other questions are peripheral.  But for many, many reasons, we have not been able to touch that question directly because of the pluralistic view we have of what it is to be human.  Nonetheless, we cannot avoid it.

And so my first point, historically, is simply this.  As you look at the history of bioethics, which really did not begin until, in my view as a bystander and not so innocent a bystander, as a matter of fact, at the beginnings of what current bioethics is, the development from a 2,500 year- old tradition of a very narrow but important topic, the ethics of the profession of medicine, began to change in the '60s, when, believe it or not, the humanities, bringing together ethics and human values, were put together as an enterprise by a group of, believe it or not again, campus ministers — the record is clear on this — who were concerned about the education of physicians wishing and hoping that they could somehow marry the technical prowess of medicine, which was then becoming very obvious with an understanding of what it is to be a human being and to use these techniques within the human existential framework.  An educational ideal, therefore, was the beginning.

This is a part of the history that bioethics has not written about.  It was only until the mid '60s that that particular thrust, which would have been very congenial to the very points you have been making here today, particularly since some of the volumes that you were talking about were being used.  Ten medical schools initiated programs, as a matter of fact:  ethics, human values, and the humanities.

Out of that grew a program supported by the National Endowment for the Humanities for a decade to stimulate the education and in- house training of faculty members in these 3 dimensions, which would enrich and broaden the medical ethics of 2,500 years, which was more or less a statement of norms without justification and norms without realization of the complexities of their application in the human situation.

It was not until 1972 when bioethics was baptized in two places, by the way, at the University of Wisconsin, as has been pointed out, but also at Georgetown, and baptized in two forms:  one, an interdisciplinary broad approach, which included the humanities; and the one at Georgetown, which emphasized strongly the philosophical approach, ethics as a formal discipline.

You know the current development.  Currently bioethics has become so broadened that it embraces almost every discipline in the humanities and in the humanistic end of the social sciences spectrum, so that we range from law to psychology to anthropology to economics, et cetera, et cetera, et cetera, because the problems involve those issues.  But the stories that one gets from each of these approaches bring us back to the kinds of questions which your anthology raises, how do we from the point of view of what it is to be human answer and respond to those questions?

Bioethics, therefore, has flourished.  It has grown.  And in its growing, paradoxically it has moved away from its central issue or the one that you have pointed out repeatedly, what is man, what are humans for, and can ethics be, again, as a phrase from your introduction says, can ethics be in the service of bios?

My second question, then, is, given that the move away from normative questions, from questions of a foundation — and it's popular, as you know, today to resist foundations in philosophy.  To move away from foundations deprives us of some groundwork to which to return so that the questions you have asked here, those acute questions, will have some basis from which to work.

Now, the paradox is my second point.  The paradox, of course, is that we have no agreement on what it is to be human.  And, of course, all of the things we have been talking about contribute to that dialogue, but we need to return to the tackling of that question.  It is the most difficult question in a democratic, pluralistic society.  Yet, it cannot be avoided.

When one avoids it, bioethics becomes a matter of procedure, an abandonment of the search for the right and the good.  It becomes a matter of dialogue, a matter of whatever it is we can agree upon is the right answer to whatever decision we have facing us.

And that spirit runs through much of the bioethics literature today when it comes to the application to particular problems.  That, of course, can only be chaos unless one is willing to accept that the true and the good can be arrived at by plebiscite, by agreement, by compromise, by contract.

Talk about what it is to be human raises another paradox.  And this is the second one.  I'm coming close to my end.  And that is, which of the very ideas and images which emerge from your anthology should one select?  Does one select all of them to go in all directions at once?  Does one select an idea or an image?

An idea, if I may be permitted — and I ask your forgiveness — an idea in my view to use a more ancient kind of definition is an intellectual representation of the essence of a thing, what is it and why is it in a general and universal sense.  An image is a particularized existentially described, multiply examined, concrete human being.  Socrates is an image.  Jesus is an image in many ways.

Do we go the image route?  And I think here is where the humanities help us enormously by giving us images.  But then which image do we follow?  As I pointed out, does one go The Iliad route or does one go The Aeneid route and the most important question, let's say, of almost capital punishment, justice, or do we try to discern what it is about us as human beings that makes us different?  That question we have run away from since the Enlightenment.  There are people around this table who can say much more about that.

And I will say it further.  My purpose here is simply to raise the questions from the point of view of a long involvement in where we are and the great importance of carrying forward this notion of bringing together the humanities and the philosophy.

The last point is what can we do about it.  Everyone will talk about interdisciplinary programs, et cetera, et cetera, et cetera.  Yes, ethics is an interdisciplinary activity, but it has its particular contribution to make, the orderly, formal, systematic examination, in the light of the concrete existential situation, those two in dialogue with each other.  And I presume your volume does that, raising the questions, but does not go further from the resolution, not necessarily resolution but the fleshing out of those questions in a more advanced and formal way.

I think if we are to resolve satisfactorily the issues with which you are wrestling — I was here yesterday as we heard about whether one should decide about one's granddaughter, should she be given ballet lessons or ice skating lessons, so on, which revealed to me a certain lack of understanding of this very question you are looking at.  Whether she, the granddaughter, has a PET scan which indicates that she would be a wonderful snowboarder is inconsequential.  Is this what she wants?  Is this how her life will develop given its particularities?  And here's where the humanities come in.

And then should one admit into the picture what the PET scan shows about her and the way her brain lights up when you talk about skating, as compared to running an automobile around a track at NASCAR?

So I want to end, therefore, by saying we need to — and you have heard this over and over again.  Having been a university president and so on, I am rather skeptical about top- down organizations that have interdisciplinary programs.  They don't work or if they do, they come up with rather mundane answers to questions.  I do think we need to stimulate discussion among and across faculty members.

This causes me to end my comments with a little anecdote of the first time I met Richard Selzer.  We were both faculty members at Yale.  I had the temerity to organize a cross- campus colloquium with people from the humanities and those few in medicine who were interested in that engagement.  Richard was a member of that group.

On those occasions, we were always enlightened by his grasp of the existential and, on the other hand, by a philosopher like Maurice Nathanson asking the questions you're asking in the first part at each of these selections you have chosen.

Is it conceivable that somehow the faculty colloquia could be one starting point for this, which might spread to students, as it did in our particular instance, and actually end up in jointly tought courses.

This won't do it all.  The final comment I have to make is that no democracy can survive without a sufficient aliquot of its members instructed and able and capable of critical thinking on the questions that the liberal arts always emphasized, the questions of what is the right, what is the good, what is the true, and what is the beautiful.

These are not to be decided by leaders, by congresses, by democracies, or by anyone else.  They are the result of an educated populace entering into the dialogue and dialectic, a combination, therefore, of philosophy as well as ethics.

Thank you.

(Applause.)

CHAIRMAN KASS:  Chairman Cole has to leave now.  Bruce, thank you very much for being with us this morning.

(Applause.)

CHAIRMAN KASS:  Paul, do you want to comment in response before we simply throw it open?

DR. CANTOR:  No, not really.  I mean, I just —

CHAIRMAN KASS:  You're content?

DR. CANTOR:  Yes.

CHAIRMAN KASS:  The floor is open for discussion.  Bill May?

DR. MAY:  I will just try to compete against the rally next door.

CHAIRMAN KASS:  Let me say a word about that.  You may be wondering what is going on there.

PROF. SANDEL:  They are cheering the report we issued yesterday.

CHAIRMAN KASS:  You are very close.  It is the staff retreat for the Washington Post, staff retreat.  Let the record show.

Bill May?

DR. MAY:  I take it what this book does is attempt to ratify what is already going on, which is an attempt to enlarge the canon.  So much of bioethics in the 30 years that I have been involved in it has attempted to draw on a limited canon.  And wonderful things were accomplished:  Aristotle, Kant, Mill, Nozick, and Rawls.  And it's been really quite impressive what ethicists have done pushing the discussion at issues of autonomy and so forth.

To include this rich range of literature that this volume does suggests that bioethics needs to enrich what goes on by working against at least two sources of abstraction in a society like ours.  One of the abstractions is science.  The other is the abstractions of politics.

Again, science accomplishes a great deal through the generalizations that it achieves, but the very procedure of acquiring knowledge in science requires so often the elimination of variables as one gets at something undistracted by its embeddedness in other things.

The poet Yeats once complained about the abstraction of H2O by saying, "I would like a little seaweed in my definition of water."  That trafficking in images and metaphors and so forth, that is, the business the artist does, it insists that we are not simply in need of universals but sensitivity to universes, Michelangelo's Pietà, Antigone, and so forth.

A particular issue, no, not simply a particular issue, but an imbedded universe.  And, after all, in a clinical setting, physicians deal not simply with the abstraction of diabetes or prostate cancer, but they deal with this embedded in the human being, seaweed and all.  And so we really do need the work of the artist in carrying forward the work of those who wield this enormous power which science has helped to generate.

On the other hand, there is the problem of the abstraction of politics.  And there are tragic limitations to politics.  I do not want to dismiss its extraordinary importance.  It is a way of organizing people around ideas and ideals, which in certain ways extant political orders may have been insensitive to.

And so political causes arise in order to retrieve ranges of human experience and human suffering and human deficit that you need the society organized in such a way to attend to.  But at the same time, there is a price to pay.  Politicians perforce organize us around ideals, but eventually the idea of justice and so forth sloganizes.

And in the course of mobilizing people for action, which is so important, there is an abstraction from the full range of human experience.  There is an impoverishment of language that goes on which eventually yields an impoverishment of community.

And so what the artist does — and this book is simply full of people who come out of especially the verbal arts — is attempt to retrieve language from its constant perishing.  And in doing that, they're retrieving ranges of human experience that are out there in the culture at large but that have not yet been fully articulated and honored in the course of its needful recovery.

And so when the artist freshens language and freshens insight and articulates experience, it helps to compensate for the tragic limitation of politics and retrieve community from its constant perishing.

So I salute this accomplishment on the part of those in staff who have worked at it.

CHAIRMAN KASS:  Thank you very much, Bill.

Let me raise a question for you, Ed.  It's prompted by your remarks.  While embracing the contribution of imaginative literature to our deliberations for their ability to give us the concrete particulars, the enfleshments of various ideas in their particularity, to give us certain kinds of powerful images that are sometimes more vivid and compelling than abstract argument, you, nevertheless, I think — and I think it is more evident in the paper that you gave us as background for the talk — that you finally think that the court of last resort is philosophy or philosophy/theology but that finally the quest for the universals and the ideas has to take primacy.

Second, a second complaint about — and this complaint could be registered not just about the imaging character of literature but could even be addressed to the history of philosophy as a whole, the belief that there must be a singular truth, but we have multiple opinions about what it is.  I wonder how you would respond to a kind of double- barreled, not such a critique but to an answer.

First, sometimes the idea and some kind of universal is absolutely best grasped through a particular in which you see through a particularly vivid image something that you couldn't possibly get in an argument but is, nevertheless, the case.

I am not sure that you could make an argument, you could make an argument that would capture the truth in the meeting of Achilles and Priam in Book XXIV.  You read it.  You see it.  You feel it.  And if you don't see it, there's something the matter with you.  No amount of argument is going to enable somebody to see the humanity of that moment where Priam embraces the killer of his son and both men weep.

So I am wondering whether you don't sell short the capacity of images to yield intuitions about truths that discursive speech can't produce for us.  That would be one point.

And then while I am not unfriendly to the quest for the answers to the great questions, we engage in it.  It seems to me if the history of philosophy has taught us anything, it is geniuses don't agree.  And it may very well be that it is sufficient unto the day to keep the questions alive and keep the most powerful alternatives in the conversation because the ultimate truth might, in fact, paradoxically embrace their differences and not find out which in the end is going to be successful.

So this is an argument that would say the presence of multiplicity of viewpoints — sure, we have to act.  And there comes a time where you have to say, "This way" or "That."  But the complexity that people face when they face hard choices may very well be a reflection of the rather complicated truth of the matter and of these longstanding opponents.

Somebody who is interested in the kind of univocal truth would say with, say, Descartes, "I looked at the history of philosophy.  There isn't anything on which the great philosophers agree.  They must have been asking the wrong questions.  We're going to start over someplace else; whereas, it seems to me a wiser person would say when they read Lucretius, "He's got something here" and when they read Aristotle, "He's got something here" and one can hold these things in mind and maybe even have a richer view of what the truth of the matter is.

So these are two different ways to lean against I think what I heard you say or what I thought was implied.  And I wondered if you could come back on that.

DR. PELLEGRINO:  Well, there is a lot to come back on, Leon, but I will just take one or two points.  First, I in no way take exception with your point that when we actually make decisions, we may be making it very often intuitively without going through any rigorous analysis.

And that's why I think it's so important that there be this dialogue, the ecumenical model that I put forth on the paper that I gave you but I did not talk about here.  And that does not give priority to one or the other but assigns to each its particular task.

What I am propounding here, I suppose, is the Medieval notion of the formal object or the material object of a study.  And I see the differences between literature and what I called in the paper the sciences and the studies of particularity, being valid on their own, and the sciences of the generality of the universal or the abstract, having theirs to contribute.

I, therefore, applaud the difference.  My only concern with bioethics is that I see one facet of this dynamic equation being pushed out and people using psychological arguments, using images, stories, characters.

And I come back to my question, which of the images do you follow?  Do you follow Dostoevsky?  Do you follow Nietzsche?  Do you follow any of these figures in literature?  They're all interesting.  They all represent aspects of the human condition and, therefore, are extremely useful.

I happen to be an inveterate reader.  So I am continually torn by these images.  But one needs to have some apparatus to step back.  I am not suggesting that having the apparatus means that everyone will come up with the same answer.  What I really am saying is I want to reserve the critical faculty when looking at something which is emotionally moving.

I am firmly convinced that if I want to teach something about compassion, let us say, to medical students — and, by the way, I am still teaching medical students and still seeing patients — when I want to get that across, I don't do it, I can't do it by a speech.  I do it through the agency of a creative writer who can evoke in a young person who has never experienced death, sorrow, pain, suffering, can evoke that experience.  And then I can begin to work with that to say, "Well, now, let's step back and look at that experience."

So I do not see it as a mutually exclusive choice in any way.  Merely the concern I have is the push, strong push, when I hear about narrative ethics.  It's important.

But whose narrative do you believe?  How do you know the story is a good story and is a right story?  That's the question I am raising basically.  And I am sure this Council is aware of that.  I am belaboring the obvious, but it seems to me that it is a very important matter as you look at and make statements, as you will, undoubtedly, probably in the future, about what enrichment of bioethics entails and requires.

On Bill May's point of politics, Bill, again, I see the realities of politics in the decisions and so on, but I do think we need some order of priorities.  And politics, it seems to me, does not determine what is right or good unless you follow that particular theory of right and wrong.  There is, whether we like it or not, a theory of morals behind every one of those acceptances or images that we take to our own.

I am reminded of Alan Donagon's preface to his Theory of Morality, in which he talks about precisely something like this, Bill, his engagement with the social issue, the political issue, deep personal engagement, his reading of George Orwell, the entrance of literature into the picture, and then his saying to himself, "Now, wait a minute.  How do I decide for myself what is the probity of truth of Orwell's position in 1984?  How do I critique it?"  And so he became a philosopher and produced a wonderful Theory of Morality.

It doesn't mean everybody should go that way.  The point is here is literature stimulating the philosophical question.  Therefore, I see it, having been trained in chemistry and physical chemistry, being in my research bag — the idea of the dynamic equilibrium, in which both sides of the equation are in constant reaction, one with the other, Bill, is the metaphor that I would use.

CHAIRMAN KASS:  Paul, could I draw you in on this?  Does the literature have something to say in response to this exchange or do you have something?

DR. CANTOR:  Well, I basically agree with Mr. Pellegrino that what it does is make these choices, these issues more concrete for us.  And that's why I was using Victor Frankenstein as a perfect example of a scientist who ignored the concrete.  I am just so much in agreement that there is not much to contribute.

CHAIRMAN KASS:  I have Gil and then Michael Sandel.

PROF. MEILAENDER:  First, maybe we could come up with some readings about how contemplative prayer is the essence of a retreat.

(Laughter.)

And we could put those forward for reflection by anyone who might be interested.

Apart from that, I wanted to comment on the two issues that you had raised, Leon, because in a sense, insofar as you and Ed are tilting in slightly different directions, I want to go with you on the first one and Ed on the second one.  I do think it's true that, at least sometimes, it may be possible that a piece of literature, for instance, actually gives us a kind of insight that discursive reason actually cannot.

So you read or see Oedipus, and there is a sense in which you see free will and fate, or determinism reconciled.  You sort of see it and taste it in a way that probably no theory has ever managed to work out satisfactorily, actually.

I do think that there is something to that.  I don't know how often that is true, but I think sometimes, at least, there is a kind of insight there that is just not available through simple discursive reason.  So I am with you there.

On the second point, though, I do think that keeping the questions alive, though a very important undertaking, — I don't dispute its significance — is not sufficient, not sufficient for this body, not sufficient for anybody in his or her life.  We need something more than that.

I think that it is a mistake for us to suppose that the model for living is the academy, where we really do just keep the conversation going sort of, but there is a reason you are an undergraduate for a certain number of years.  There's more to life than just that.

And there are moments when one really does have to decide, and your decision may be enriched in countless ways by the questions having been kept alive and kept alive in sort of fruitfully complex ways.  But that doesn't alter the fact that you can't just find yourself in the midst of a series of questions, but you, indeed, must act and decide.

CHAIRMAN KASS:  Michael and Frank.

PROF. SANDEL:  My question is for Professor Cantor, though I want to say first that I am sure we all appreciate your situating our work in the sweep of history from Emperor Augustine to Emperor Leon.

My question is about the Wordsworth passage that you read having to do with the relation between science and nature.  It was striking to find a Romantic poet affirming the link, rather than insisting on the opposition between them.

Often in bioethics arguments, people cast science and argue against a scientific intervention on the grounds that it is unnatural, whether it is flying to Mars or embarking on asexual human reproduction; whereas, other people reply, "Well, science is natural in the sense that it is an expression of human nature.  So it can't be cast as unnatural, whatever else might be wrong with it."

The passage from Wordsworth included a striking phrase, the one that you read, where he described science as "the lawful offspring" of nature.  Is Wordsworth telling us there that, whatever the pros and cons of a particular scientific pursuit, that no scientific pursuit can be condemned simply as being unnatural?

DR. CANTOR:  I don't know that he ever worked out his thoughts sufficiently on that, but it is interesting that he does see it as part, an integrated part, of the human enterprise.  Shakespeare does something very similar in The Winter's Tale when some characters complain about grafting, that the wrong bud has come out of the vine because grafting has taken place and it is unnatural.

Shakespeare's characters say something like "Art uses no means, but nature doth make those means," again that sense that art and nature are not radically opposed, that we are human beings and part of our nature is to create art and to pursue science.  And it is true.

Even in Wordsworth's famous Preface to Lyrical Ballads, he talks about the imaginative possibilities of science and predicts that someday there will be poets drawing their images from chemistry the way they have hitherto been drawing them from what we think of as the natural world, the world of trees and mountains and so on.

I brought up that one sonnet because it does fill out our picture of Wordsworth.  I mean, this is the same man who Ellsworth says, "We murder to dissect," a much more famous line from Wordsworth which shows a kind of kind of fear of science, particularly medical science, and where it draws its knowledge from.

I hesitate to put too many words into Wordsworth's mouth, but I think the example I cited from Shakespeare and this one sonnet show that there have been moments when even the most romantic of poets have tried to see the continuity between science and other human activities.

Now, I think the point that Wordsworth would make — and he does gesture towards it in this Preface to Lyrical Ballads — is that for us to see this connection, science needs to be integrated into broader human activities.  That's, indeed, the role that Shelley argues in his Defense of Poetry for the poet that science is potentially in harmony with poetry, but the two can diverge.

I do think that this romantic generation believed that there could be an unnatural direction to science.  Surely, that's the thrust of Frankenstein.

So I was just trying to correct what I think is a one- sided misperception, even of Romantic poetry, but it is really right to focus on that one line, which is so counter to what we normally think of the Romantics as doing.

CHAIRMAN KASS:  Ed Pellegrino and then Frank.

DR. PELLEGRINO:  I just wanted to add that I didn't mean to shortchange science in this dialogue.  For want of time, I concentrated on what I thought was to be the major focus of the anthology.

Again, I think just Colvino's thoughts happened to flip into my mind.  He pointed out on his dialogue between literature and philosophy that it was no longer a double- bed marriage.  It was a menage- a- trois.  And science was the trois.

Now, Bill would suggest it would be a- quatre, but I'm not sure that the bed is big enough for all of them.  So I would put science, philosophy, ethics, and literature into a dialogue or trialogue with each other.  And I think that is essential today.  So I don't want to lose that point at all.

I would see science, again, as among those disciplines of the particularity, science per se not being able to establish what we ought to do.

CHAIRMAN KASS:  By the way, people should know that there is a section of the reader called "Scientific Aspirations" in which we have accounts, in four cases I think first- person accounts, of the scientific aspiration as told by the practitioners and a fourth remarkable account of the life of Archimedes from Plutarch.  They don't all say the same thing, and even the modern ones don't say the same thing.  And they don't exactly say what, Paul, you have characterized to be the intrinsic aspiration of the activity.

Science's account of its own self- understanding is not excluded from the humanistic account because science is one of the human activities par excellence.  So I think we have tried to make a place for that here.

Frank, please.

PROF. FUKUYAMA:  I am disappointed for the way this has gone so far because Paul Cantor, if he is known for anything, is not known for his high- minded discourse on Wordsworth but his extremely acute observations on popular culture and what they tell us about the way we see ourselves.  He has written on The Simpsons and Star Trek.  His most recent book was on Gilligan's Island.

So I don't have a question so much as a Cantor- like observation about one of the popular culture points of reference that you mentioned, which I think is actually quite relevant to the discussion that we had on neuroscience yesterday, which is the movie Blade Runner.  Maybe you can react to this.

Those of you who have seen the Ridley Scott movie, it is a brilliant movie.  It's based on a book by Phillip K. Dick called Do Androids Dream of Electric Sheep?

Now, those of you who have seen the movie, it's about these replicants who are androids that are brought back from an off- world colony.  The whole theme of the movie is that they actually develop human emotions.  They are machines, but they develop human emotions.

There is a lot of religious symbolism as the end.  It turns out that they suffer and they feel empathy and pain.  In fact, there is an image at the end of the movie where there is a nail being driven through the hand of the chief replicant as he is being destroyed.  He kills his creator in a Frankenstein- like way.

What is interesting about that movie is that it is completely different from the underlying book, which made almost the exact opposite point.  If you read the original Phillip K. Dick, he was kind of a hack writer who wrote desperately to keep alive.  His writing, he is not a great stylist, but his imagined android was not one that had developed human characteristics but one that was missing empathy, was missing a key human emotion.

Actually, the replicants in that story try to undermine religion.  There is a religion called Mercerism that is based on the feeling of empathy.  And the replicants actually expose Mercer as a fraud and disabuse people of the need for religion and so forth.

It does seem to me that it points out a couple of things, that literature is actually extremely good for enabling us to picture both what it means to be human but also in a sense what it means to be inhuman.

So maybe, Rachel, now that you have completed this book, you can work on one called Being Nonhuman because in a sense, it might better articulate what some of the fears about the future are.

It also does seem to me the change between the Phillip K. Dick version and the Ridley Scott version in a way reflects the change in the broader culture, this greater confidence that our materialistic understanding of what it means to be a human being has somehow displaced an earlier, more religiously based one, which said that there is something in a certain sense unduplicatable through any mechanistic device that would actually truly replicate what it means to be a human being.  So I wonder if you might say something about that.

DR. CANTOR:  First of all, I would suggest the next volume would be called Being Inhuman, pursue that line.

I was trying to justify Leon Kass' choice of me by largely avoiding popular culture this morning, but I did praise the volume for including Gattaca and actually mentioned Blade Runner at that point.  Indeed, I do think it is relevant that the kind of inquiries represented by most of the selections in this volume are being continued in movies, in television, and, in fact, our popular culture is coming to grips with the very issue that is being raised here.  I would, in fact, put in a plug for that.

Half of my book Gilligan Unbound deals with The X- Files.  And nothing in our day has confronted more directly the very issues that you are talking about in this volume, the very same issues and what it is the human, with these aliens trying to imitate humans, the alien bounty hunter who can take the form of a human but doesn't have human emotions.

I think it is actually fascinating that one of the central motifs of our popular culture ever since Blade Runner has been the question of how you can distinguish human beings from various forms of androids.

Some of what is in the original Dick story does survive in the movie in that these replicants look like human beings.  They give them psychological tests to try to figure out if they are human beings or not.  And one of the things they are testing for is whether the being has empathy or not.

The entire Terminator series, I, II, and III, has raised this issue, especially the very strange Terminator II, where the Arnold Schwarzenegger character turned out to be a better dad than the real live human being dad that the Edward Furlong character had, and the very strange sense that, again, this machine that had to learn emotion and when Arnold generates a tear there at the end, we all know he is a very good actor.

(Laughter.)

DR. CANTOR:  So I have been fascinated by the — he's playing a governor now, but —

PROF. GEORGE:  Will he be better than the real live human being governor?

DR. CANTOR:  Who knows?  It really struck me how much our popular culture has tried to come to terms with specifically this issue.  As we increasingly enter an electronic and cybernetic, cybernautic age, we really have had an enormous series of images in movies and television that raise precisely this issue, what is the dividing line between a human being and a machine, when do computers develop consciousness.  That's been a tremendous theme going back to the Kubrick movie 2001.  It came up in a number of X- Files episodes.

So, in fact, I think there is quite a continuity between what we think of as high culture and our popular culture.  Again, that is why I praise the anthology for including something from Peter Pan and something from Gattaca.

CHAIRMAN KASS:  Dan Foster.

DR. FOSTER:  There is a huge movement to try to get some sort of marriage that's oftentimes used between science and religion, for example, or in the case here we're talking about some dialogue or interactions between ethics and philosophy and serious questions about what it means to be human.

There was a little book that Stephen Jay Gould wrote that I haven't found very many people read, but I read it and I thought it was pretty interesting.  It's called Rocks of Ages.  He wanted to address what he called the incorrectness of trying to marry these two disciplines, science and religion.

In several cute ways, he says science is about the ages of rocks and religion is about the rock of ages.  He coins a term which he calls "NOMAs, non- overlapping magisteria."  He took the term "magisterium" from the Roman Catholic Church, which decides what questions you can ask and what answers you can give.

His point is that the magisteria do not really overlap.  They ask different questions.  Science is interested in how the world began.  Religion is interested in who may have made it.  Science is interested in how do human beings come to be.  And religion, as has already been said, asks "What does it mean to be human?"  He says these are not overlapping questions.  I think that is something that we need to try to keep straight.

The disciplines are different.  And the focus is different.  In one sense, particularly on the scientific side, there is not much interest in the issues that we are talking about here.

Somebody asked me last night — I can't remember — do scientists in general, particularly the great scientists, have a sense of the solemnity of human life?

I would say in multiple conversations that I have had, that that rarely surfaces.  The sort of questions that we address here may surface in terms of personal disaster or risk.  If somebody gets sick or they're dying or something like that, they will ask sort of universal questions, but I think that it is a hard sell to try to say what occupies people in literature and philosophy to get the scientists to think about that in a serious way.  They're too much interested in the science itself and probably rightfully should be, just as the writers and so forth are fundamentally interested in what they write.

Now, there is a difference.  There is an imbalance here because my observations are that the people who are in the arts and philosophy and literature, almost everything that happens in science can do so enthusiastically, particularly if it looks like it might relieve suffering or save lives, so that the flow of information is essentially unilateral or close to unilateral.

Everything in science gets written up in the newspapers every week before you even get the journals to read.  So this flow, every one of the people sitting here from the other — I'm not saying the "other side," but I mean in this dialogue — will read and be interested in what science is doing.

But I can tell you that the scientists in general are not only — this is a very big danger, and I've only talked to a few scientists.  So I don't want to generalize, but I think it is true that the scientists are not only particularly not interested in what something like the Council is doing, but they are fairly hostile toward it because they see it limiting the science.

So all I am trying to say is that it would be great if we could reverse some of the flow backwards, but I myself think that is relatively unlikely and that we are fooling ourselves and what we ought to try to do is to bring up these most serious of issues and say, "These are things that you ought to think about.  And some of the things that you are doing, we are doing in science, are wrong or should not be done" and get the attention there.

So I am very sympathetic to the late Gould's view that we need to be sensitive to the non- overlapping nature of the magisteria of these two very great things that occupy all human beings.

CHAIRMAN KASS:  Ed Pellegrino, do you want to respond?

DR. PELLEGRINO:  I very much agree with the reality of the ordinary, general scientist's response to these kinds of questions, having spent 25 years in the laboratory myself, having experienced that and felt it myself from time to time.

However, I think, as you know, from time to time, there is an upsurge of interest within some scientists.  The Asilomar Conference, for example, is an example of a perception of the fact that some things ought not to be done, even though there may be very good "scientific" reasons for doing so.  We have scientists who are concerned about atomic energy and atomic bombs.

So there are signs of hope among scientists that they will look at some of these questions as very pertinent to their own way of behaving.  I understand the scientists' concern.  And I very much believe in the difference in the approach and the methodology and the evidence, but I think it's the fusion between these three ways of looking at the world that is essential for the kinds of problems you are facing.  I would hope that, I believe, and I am seeing that more and more scientists are interested in these questions, quite honestly.

DR. FOSTER:  As I have said, I don't want to generalize.  I happen personally to be one person who is interested in both magisteria.  I think that most people I talk to at the very tiptop of science, like we've got four Nobel guys at our school and so forth and so on —

DR. PELLEGRINO:  I would agree.

DR. FOSTER:  So they just are not as interested.  There are exceptions, and those are wonderful exceptions.  But I'm just trying to talk about the general reality here that I think that we need to take cognizance of.

DR. PELLEGRINO:  I think you are absolutely right, and that's true among medical students as well.  I would like to say that they have been nurtured on their mother's milk of logical positivism so that it is very hard to disengage them from that particular addiction to something a little broader.

CHAIRMAN KASS:  Last comment from Michael Gazzaniga.  Then we will break.

DR. GAZZANIGA:  I would just be curious to know, if we took Yale as an example, what percent of your professors in the liberal arts go to work wondering about right, good, true, and beautiful as their goal for their week's work.

DR. PELLEGRINO:  I am sorry.  I am suffering from a little bit of dysfunction of the auditory apparatus.  If you could say it a little louder, I would appreciate it.

DR. GAZZANIGA:  I'm sorry.  I'm sorry.  You had mentioned that traditionasl liberal arts goals included seeking right, good, true, and beautiful.  And I was just being a little bit playful here.  What percent of the Yale liberal arts faculty goes to work and has that on their mind as their week's endeavor?

DR. PELLEGRINO:  I have no illusions that we can arrive at a full perception of these concepts. In the concepts of idea and image as represented in literature and philosophy, we are wrestling with the question — what is it to be human? This is a question the Council has properly and repeatedly raised. What is common to both literature and philosophy when each engages this question? We can approach the answer only asymptotically, but in doing so perhaps we can bring image and idea closer together. This we must do if we are to have a common notion of human existence against which to judge whether any particular biotechnological advance is a good for humans, as humans.

CHAIRMAN KASS:  Thank you, Paul Cantor.  Thank you, Ed Pellegrino.  Thanks to the Council.

We have a 15- minute break.  We will reconvene at 10:20.

(Applause.)

(Whereupon, the foregoing matter went off the record at 10:04 a.m. and went back on the record at 10:25 a.m.)

SESSION 6:  DISCUSSION OF THE COUNCIL'S FUTURE WORK
Staff Working Paper, "The Council's Second Term: Agenda Options "

CHAIRMAN KASS:  Could we reconvene for what I think is going to be a very interesting and important discussion concerning the Council's future?

You have a staff- prepared working paper called "The Council's Second Term:  Agenda Options," which reviews the points of departure, reviews our major projects, offers a few generalizations about what we have done, and then sets forth some preliminary questions about what we might do next, and also then lists a series of possible topics.

These possible topics have been suggested by one or another, sometimes more than one Council member or it has come up in previous discussion.  Rather than my simply rehearsing them, you have them.  You have looked at them.  There are ten possible topics described in varying degrees of detail.

I would say two things.  We are not going to decide the question of the future agenda in a conversation of an hour and a half.  In fact, there are a couple of people who have planes to catch and may not make the full time.  So we will regard this as a preliminary round.  And what will follow this is the staff and I digesting this conversation.  We will supply additional materials for your reflection and response.

We have been slavishly productive for the first term.  When the next report comes out, God willing, in April, that will be five books in a little over two years.  No one has asked us now to do anything else.  We are somewhat in the clear.  We've got a slightly easier meeting schedule.

I think we should be free to think not only about topics but also about different forms of product.  It's not clear that everything that we do has to be the report written by members, by the Council.  We could put together collections of essays and papers.

And in the first instance, I think we should try to educate ourselves about what some of these issues are so that, even if it takes us a couple of meetings to work out the full agenda, we do it as we have done before:  invite some people in, have some discussions amongst ourselves, land on a topic that is appropriate.

So while the stakes are in a way high, I don't feel the sense of urgency.  And I think we should have a wide- ranging and exploratory conversation.

I have my own slight leanings one way or the other, but they're not strong enough even to voice them in the conversation at this point.  So I am really mostly interested to see where people are in their own thinking and whether there is anything here in the document that strikes any of you as something that might be worthwhile our exploring.

We could also invite some postmortem on the toe in the water we got yesterday in neuroscience and neuropsychiatry because it is one of the areas of interest and an area in which we have also some special competence on the Council.

Any place you would like to go is fine with me.  Paul McHugh.

DR. McHUGH:  Yes.  Leon, I would like to pick up on what you said in your last remarks and say that yesterday's meeting with the neuropsychologists and neuroscientists was very interesting and raised for all of us the place of neuroscience in relationship to our understanding of humankind.

As you heard from my slightly intemperate remarks yesterday, I, of course, believe that the issues here to be discussed ultimately relate to the issue of consciousness itself.  Consciousness, which brings freedom to nature, is a product of the body but is also something interactive with the body and a matter of phenotype that has had its role presumably in natural selection and evolution.

The issues that came up yesterday as to the predictability from the brain ultimately depend upon our understanding about consciousness itself.  So I would like to suggest that we think in terms of some devotion of some of our time to consciousness:  Its bi-directional linkages with the body.  And its evolution through natural selection and, thus, the implications of human consciousness today.

We have, of course, on our board, as you said, perhaps our country's most distinguished student of consciousness and it's bi-directional linkages with the brain in Mike Gazzaniga.  Mike has not only done the most interesting basic work of how consciousness and the brain interrelate but has done this both for the scientific community and also for the public at large.  There are other people who could speak in terms of the issue of consciousness, people like John Searle and in evolutionary terms Daniel Dennett.  Then a person whom I think also speaks coherently about the Darwinian issues in relationship to consciousness and its problems is Stephen Rose.

At any rate, the issue that we have to understand as a Council and make clear to the American public is that evolution does work on phenotype.  It doesn't work on genotype.

And clearly since Jan Smuts, we have talked in holistic terms about how the organism interacts in evolutionary terms and consciousness.  Particularly its ultimate evolution in human consciousness is an example of the power of this process and has tremendous meaning for our understanding of not only what is man but who am I and that sort.

So I would recommend that we should follow up our discussions here yesterday about what may well be the overvalued concepts on certain kinds of brain imaging to see the place of consciousness, which we cannot explain from the brain yet, as I said yesterday, and, yet, has a crucial place in our understanding of ourselves and of nature.

CHAIRMAN KASS:  Rather than simply go on a laundry list of different items, maybe I should invite people to respond to Paul's suggestion or things in the related area.  And then we will move on.

Does someone want to join?  I see Frank nodding his head, and I think Bill and Gil would want in on this, too.  Please, Frank.

PROF. FUKUYAMA:  I would just second that.  I mean, I think that the consciousness is not just an inherently interesting issue.  It is very much related to what it means to be a human being because human consciousness is really different.  It is the one thing you point to as being a kind of unique human characteristic.

So I would just say that it is very important, connected to the larger issues that we have been dealing with in this Council right from the beginning.

Also, I think it is an area where the science has so many holes in it at the moment that it is important to bring out some of where the frontier is but also what some of the limitations in the current understanding of the phenomenon are.

CHAIRMAN KASS:  Bill?

DR. HURLBUT:  Just to take your comment to its practical meaning, the concept of consciousness and its relationship to freedom takes us into what I think is an extremely important emerging territory of ethics, perhaps the most difficult ethical question of all.  And that is the question of freedom, personal responsibility as they relate to criminal behavior.

I think anybody in science and medicine recognizes that the traditional concepts that have guided our adjudications and penalties and so forth, that these are going to be challenged by emerging science.  Although that will be a long conversation of many decades, it would be good for us to start that conversation here as a Council.

CHAIRMAN KASS:  Gil?

PROF. MEILAENDER:  I'd express a reservation, not stronger than that but a reservation, about the topic.  I would be happy to have us pursue it.  There are interesting and important questions to raise.

I think the best topics, though, are topics that engage us at a theoretical level but that we can also see ways in which actual ethical questions and decisions emerge from them, so questions that sort of engage us at several different levels.

I am not at the moment persuaded that this topic will really do that.  I think it does raise some very difficult and interesting questions.  As far as I can tell at the moment, they're new versions of questions that are actually very old and have arisen in other ways.

So it would be interesting to pursue.  I'm sure it would be useful to pursue.  It would I predict result in something rather more like our "Beyond Therapy" document than like some of the other things.  I would, other things being equal, prefer to see us move in a direction that crossed, sort of held together those larger theoretical interests with something that had some sort of policy, more immediate policy, implications.

CHAIRMAN KASS:  Mike Gazzaniga, do you have something you want to say on this topic?

DR. GAZZANIGA:  Gee, Paul, you know, when you make such generous remarks like that, I think one is being set up so that after you give your talk, we say, "See how little we know."

As one who does lecture in and think, study this thing, I know how little we know, but I think there is plenty there for everybody to get their head around and to think about its implications for the sort of issues that Bill just raised, the utility of it being in terms of current concepts of personal responsibility and the notion of free will.  So I think there is a lot there, but I am a self- interested party in this.  So you should decide.

CHAIRMAN KASS:  But you are not waving this off.

Still on the same topic, Robby?

PROF. GEORGE:  Yes.  Thanks, Leon.

You know, I understand Gil's reservation, and I share Gil's view that the best topics for us are topics that engage us theoretically, engage our interests theoretically, but also have public policy value.

It raises for me a general question when I think about the exploration of consciousness and mind and freedom.  Very often I have noticed in our discussions, often our discussions with guests who come to speak to us, that a topic or the policy implications of a topic will be waved off because while the day may come when this or that problem presents itself by virtue of an emerging technology or an increase in scientific understanding.  That day is very, very, very far off.

Then other times, of course, we deal with problems that are right on top of us and the science or the technology seems to be moving more quickly than we can assimilate our own thinking to it.

So in trying to get a grip, having in mind Gil's concern here on whether I think this is a good thing to do, I would like to know perhaps from Mike Gazzaniga or I probably should have raised this question with our guests yesterday.  I would like to know how far we are from having to face real public policy ethical choices about the use of imaging techniques in the context of, let's say, criminal investigations or, well, in some of the concrete areas that were raised yesterday about prediction of behavior. Mike, I'll put it to you.

Are we 100 years off from that, in which case perhaps if you share Gil's and my view about the best projects for us, maybe we would lay this aside, or are we 20 years off?  If we're 20 years off, then perhaps somebody ought to be thinking about this now, the ethical dimensions of this now.  And there is no other somebody around with the kind of governmental license to do this.  We're it.  Maybe that's not a bad idea.

So can you say anything that would be helpful on that?

DR. GAZZANIGA:  There are concurrently running conferences that are addressing the impact of neuroscience on legal questions; to take an example of the concept of culpability, personal responsibility and what brain imaging might or might not say about what, what neurochemical studies might or might not say about that, what lesion studies might or might not say about that.  These are ongoing now.  I sent Leon a paper that I wrote on this topic.

In many ways, I am inclined to the position that in a lot of these issues, neuroscience should butt out, that they don't have anything to say about it.

So, on the one hand, the data is building that this information will be used in various courts of law.  But I actually caution against using the courts of law for a long argument that I won't get into here.

So it's on the table.  It's in the system.  The lawyers are interested.  The judges are interested.  The judges hold national meetings looking at this neuroscience data.  There is one going on at Dartmouth this summer where all the U.S. court judges come and listen to the case of neuroscience.  The neurogenetic implications, it's all out there.

The question that both you and Gil raise or your reservations are well- taken, but I think all that means is you should got into it with caution and listen to what is being said.

The basic notion that the defense lawyers and many legal scholars want to use is they want to explain away why Harry killed Bob, because of the pixel in their brain.  That's the question.  They want to remove responsibility from Harry.  Can we say that?  Is that a viable idea?  That issue is a very complex issue at both the neuroscience level, at the legal level.

So they're fascinating topics.  I think that you would enjoy them.  I don't know what we would do about them, but you would all feel enlightened by the debates.

CHAIRMAN KASS:  Charles, to the same subject?

DR. KRAUTHAMMER:  Yes.

CHAIRMAN KASS:  Please.

DR. KRAUTHAMMER:  But that eminence would make it a compelling subject for us.  Clearly we're not sure when the science will mature enough to justify these actions, but you're telling us that these actions are happening right now.

I think we could have a lot to contribute precisely for that reason.  We could study the science that people bring to us, make that public, and then draw our own conclusions.  Especially if this is just getting off the ground, I think it would be, as public policy, a terrific public service if we did this since obviously nobody else would do it the way that we would.

CHAIRMAN KASS:  Robby, still on the same?

PROF. GEORGE:  Yes, just to follow up with Michael, which that was very helpful, Michael, to know.  Could I ask you further, in addition to the defense lawyers wanting to explain that Harry performed this horrific act because of something beyond his control, how close are we to this scenario depicted for us yesterday of predicting that Harry will do it or is much more likely than the rest of us to do it and doing something about it?

I can imagine that different people would propose a range of things, some of which would strike most of us as unethical to do.  If that's close, that strengthens the case further I think for doing something.

DR. GAZZANIGA:  Well, we are getting into it now.  That is the core question.  There are people that would make a strong claim that because so and so had a lesion in the orbitofrontal cortex, this would explain why they have this violent act occur and, therefore, they're exculpable because of the lesion.

That claim is out there now.  And there are qualified physicians and neuroscientists who would argue this, the claim that that is not an okay way of thinking about it from the same group of qualified people.

So the debate is on.  I don't want to get into it here because it should be brought out in an orderly way.  You should feel confident that those issues are hotly debated and there are two sides of the question as we speak.

DR. McHUGH:  And could I just add to that?  I didn't talk with him before, before we came in this morning, but I believe that what Mike is saying is exactly what I think is the important things to be done here and that yesterday it was not only the material that was being presented but the stance that was being presented towards the issue of brain and brain predictability about things which ultimately are going to play themselves out in consciousness itself.

And until we as an ethics council really understand the limits that the brain work can do for us and the place of consciousness in its bidirectionality to the brain, I think we will miss an opportunity to engage the public in a more coherent view of where neuroscience is today.

CHAIRMAN KASS:  Bill May, Michael.  Charles, is your light on?

DR. MAY:  It seems to me that the level of payoff, an application, not simply the forensic issues but also medical issues of care, of Alzheimer's patients and arterial sclerotic conditions, where you face personality changes and so forth.  And that relates to the perceptions and consciousness of the world.  So it's not simply forensic issues but also issues in health care that would surface here at a practical level.

CHAIRMAN KASS:  Michael?

PROF. SANDEL:  I want to just add my voice to what seems a strong sentiment around the table.  Recall that the sessions that we had with Pinker and with Cohen were among two of the most engaging and lively and interesting sessions we have had.  Then with practical implications that have just been even hinted at here, I think this would be a terrific topic for us.

CHAIRMAN KASS:  Charles?

DR. KRAUTHAMMER:  I would just add that I found the most compelling part of the presentation yesterday was that clip from CNN Headline News.  You can see how imaging is so translatable to popular culture that I think it will soon be used a lot to justify all kinds of crazy stuff.  And it seems to me that since that is just starting, we could really contribute something by bringing a bit of a reality principle and just putting out the facts.

For instance, I was interested to learn that there is a five- second delay between the lighting up, which I had never heard of before yesterday.  And I read this stuff reasonably carefully.

And I think we would have a lot to contribute in this area, I think it is a natural for us.

CHAIRMAN KASS:  It sounds like there is, if not unanimous support for this, very strong support.  Let me make a suggestion.  I don't say I have a reservation.  I have a concern about how to organize this and how to focus this so that we are not doing everything conceivable under this subject.

My suggestion is the way we should proceed is some staff work with the help of our experts on the Council.  This means not just experts on the technical side but the kinds of questions that we would like to have raised, forensic and other, and see if we can't use the next meeting or two to begin to bring in some additional people who could inform us on those subparts that we would like to learn about and, by collecting certain kinds of readings that we can discuss amongst ourselves, explore this further and try to define it in such a way that we know what we are doing and not simply, at the taxpayers' expense, enjoying ourselves in interesting speculations.

I would like this to be somehow a useful thing.  I can see lots of ways it could be.  But I think we have to work pretty hard in order to formulate it so that would have a pretty good chance of happening.

Is that agreeable as a strategy for going forward?  Mike, please.

DR. GAZZANIGA:  Well, I was going to offer another suggestion that would contrast with this, equally as interesting, I think, but I think fulfills for the people who have reservations' agenda.  That would be to have a full session on what modern science knows about the developing mind of the child, both from a neurobiological point of view and a neuropsychological point of view.

Yesterday we heard from Bob Michels all of the ideas of sorting kids by capacity and all of this sort of thinking.  In there is sort of an implied "genes-are-destiny" sort of pitch.  I don't think there is any modern neuroscientist who really thinks that.

So the thing that I think we should all educate ourselves on is what is known about the developing brain; what is known about the young child's mind; putting it crudely, what comes from the factory, what doesn't; what are the concepts that are built- in, which ones are learned; what is the extent that it is malleable and plastic, what is the extent that it isn't; are things like temperament more under genetic control than intellect?

All of this stuff is well worked on, well thought- out.  And it would set the context for so much of the discussion about possible implications for education or not education in a long list of the child.

CHAIRMAN KASS:  Right.  Suggestion.  It is sometimes much more economical for us to read than to simply bring some people in to listen to them make a presentation when the papers or an article or a short book is available.  We are simply going to ask you, Mike and others here, to produce a kind of bibliography.

This is a new terrain for probably most people here.  We can do some of our homework on this one between meetings by reading, especially if it doesn't come ten days before the meeting.

If you can get us some references of things to get us up to speed, that would be very helpful.  And we can use our invitations more selectively against an informed background.  This would be a very exciting thing to learn about.

Dan?

DR. FOSTER:  But I really want to speak strongly to have live humans come in here to talk —

CHAIRMAN KASS:  Oh, of course.  Of course.

DR. FOSTER:  — because the most important things we learned were in questioning, not in what they said.  So I hope you're not arguing for simply a reading.

CHAIRMAN KASS:  No, no, no, but that if Mike says, "Look, there is this massive amount of stuff known about the developing mind of a child" and some of this we could get by reading and then get an expert in when we're suitably prepped, absolutely, Dan, I agree.

Can we move from the neuroscience?  Janet, please.

DR. ROWLEY:  You know, it does suggest itself that there could be an order since, to at least some of us, both topics have attractions, that if we followed Mike's suggestion first and got a little bit more understanding of the development of the brain and then went into the area of consciousness, that would seem a more logical order than the reverse.

CHAIRMAN KASS:  Bill, do you want to say something before we move on?

DR. HURLBUT:  Just to affirm what Mike says, these are very much related issues.  For example, the work of Antonio Demasio has shown that the development of certain empathic capacities relates to later antisocial behavior.  And it would also be a realm, development would be a realm, where interventions might be a very practical concern ultimately.

CHAIRMAN KASS:  All right.  Other topics?  Rebecca and then Mary Ann.

PROF. DRESSER:  I support the neuroethics investigation, but I think a nice counterpoint and something much more down to earth would be some version of number 3, the elderly biotechnology and bioethics, focusing on dementia and end of life, the overlap or separately.

Gil and I were talking.  I said, "I think this is an area that is pseudo settled in policy and ethics.  There was a lot of discussion 20 years ago, 15, 10."  It has died down.  Now with this Florida case, it has come back into public consciousness.

There has been a sense that, "Well, we just need to make a living will, an advanced directive, and everything will be settled."  That's not at all accurate in practice or in policy.

The last three high- profile cases have involved family disputes, patients who had severe brain injuries, some statements, former statements, about "This is how I would like to live" and so forth, but nothing specific.  There really is very little guidance on how to proceed in those cases.

I think we could make a big contribution and then at a higher level just a group like this talking about what does death with dignity really mean today for our country and different individuals, how should we think about it, how should clinicians think about it, how should people think about it for their family members and themselves.

I think it is an intrinsically interesting area.  And I also think it would be something to work on in parallel with this more speculative area that could make a contribution to the people who are paying our per diems and so forth.  I think it is very much needed at a practical level.

CHAIRMAN KASS:  Continuing on this topic, Charles.

DR. KRAUTHAMMER:  Yes.  I would like to strongly endorse that.  I do think this is an area that really needs or could use analysis.  The Schiavo case in Florida did bring it up again.

It seems to me that it is cyclical.  We get interested in this.  Every 10 or 15 years, there is a case.  Right now there is a kind of a lull.  We had the euthanasia debate in Oregon and, of course, Holland.  That is going to come back.

It is now quiescent.  We have got a war, and we have other things to worry about.  I think it is precisely because the debate is quiescent now that we could do some rather measured work on that.

I do think euthanasia, which is sort of one aspect of this and perhaps it is the extreme case, but the whole study of end of life, death with dignity needs a modern or a recent new look at.  I think we could do it.

So I would like to very strongly endorse that.  Some people will say it is another sign of the narcissism of the boomers, "Now that we're going to die, we want to study this," but I think it needs study.  And I can't think of a better group to do it.

CHAIRMAN KASS:  Alfonso?

DR. GÓMEZ-LOBO:  On the same line, I really think it would be important to study these topics of end of life.  Now, I find the question of the general care of the elderly very important, I mean, not just euthanasia but as our population is aging.  As families are smaller and smaller and people are put away in some nursing home, et cetera, I think there may be for us as a community some very important ethical issues.  How do we treat these people who have given us so much as grandparents, parents, et cetera?  And there may be, for instance, interesting findings with regard to that topic.

I admit that theoretically it is probably less interesting than any of the other topics than euthanasia, but I sense that there is a real question of justice involved in the care of the elderly.

CHAIRMAN KASS:  On this topic, Gil?

PROF. MEILAENDER:  This was the topic among the things that I was going to recommend before you all buried me under your support for the neuroethics proposal.  I actually still think it is the best.

It raises some very interesting theoretical questions, actually.  The questions about personal continuity that dementia raises are fascinating and every bit as complicated as any other.  But it also touches something that is about as fundamental to our humanity as it is possible to get.

So there is that sort of rich human dimension to it.  There are some complicated theoretical questions, and there are clear policy kinds of things.  It just seems to me to have all of the elements that a really good topic would have that we could do something that is intellectually interesting and also genuinely useful.  So I think it is a good topic.

DR. KRAUTHAMMER:  Could I add one point?  It is missing an element, embryos, which makes it extremely attractive for that reason alone.

PROF. MEILAENDER:  The demented person was once an embryo, Charles.

DR. KRAUTHAMMER: Well, it doesn't involve a decision about that.  And because of that, I think it will allow us to recapitulate a lot of our other debates, removing that element, one that is sort of in some ways beyond discussion and debate and compromise and will give us an arena to have our other discussion I think uncontaminated or have I given away our game here?

CHAIRMAN KASS:  No.  You have now changed the debate from the debate about the embryo to the debate about whether we should not debate about the embryo because Robby wants to say something.

PROF. GEORGE:  Well, this time I am the guy who will raise the reservation.

DR. KRAUTHAMMER:  Don't you dare.

PROF. GEORGE:  And it actually arises out of what —

CHAIRMAN KASS:  Oh, come on.

PROF. GEORGE:  No.  Honestly, it honestly does.

And here is the reservation.  The reservation is if we go to questions of euthanasia and physician- assisted suicide — now, there are other questions, like some of the ones that Bill and I think Alfonso have talked about, care of the elderly issues, on which I don't think we have this problem.  If we go to those very controversial issues, the Council will be divided in a very fundamental way, the way we were on embryos.  And, in fact, it's not —

CHAIRMAN KASS:  That's perfectly fine.

PROF. GEORGE:  It's not —

PROF. SANDEL:  How do you know it will be the same division, Robby?

PROF. GEORGE:  No.  I am not saying it will be the identical division.  I am saying in the same way, not that the same people will line up on the same sides, but it will be in the same way.  And it will be in a similar issue.  It is going to be the issue of personhood and whether there can be post- personal human life, just as we argue about whether there can be pre- personal or pre- conscious human life or post- conscious human life.

Argue with me.  Explain.

DR. KRAUTHAMMER:  I will argue with you because I think that you —

PROF. SANDEL:  You don't have to argue because, Robby, this is a reason for taking it up.  So you agree.

DR. KRAUTHAMMER:  Empirically if you look at our discussions earlier on, if you get past — I don't know — six months of gestation, I think all of us are unanimous here.  It's the early stuff that was uncrackable.  Certainly at the point of birth, that issue doesn't exist.

PROF. GEORGE:  Charles, look at the literature.

DR. KRAUTHAMMER:  May I?  I'm talking about our own history here.

CHAIRMAN KASS:  I think it would be premature, since you don't have your imaging of all of our brains, it would be premature to guess how the discussion in this matter is going to turn out.  Yes, there are life issues here, but there are life issues that don't depend upon whether you think the embryo belongs in the conversation about the life issues, the early embryo.  That would be one point.

Second, I was originally very skeptical about this.  In fact, in the original executive order listing all the topics that we might consider, end- of- life issues I think is the last one or something like that.  Actually, I probably have it in front of me, but it was tacked on there by someone in the White House who wanted to make sure that this was partly our agenda.

And I sort of winced because this is a tired subject.  People like Charles and myself and others who have written on this subject, assisted suicide and euthanasia, felt, "What else is there to say on this matter?"  But the more I have thought about it, the more I think there are good reasons for us to take it up.

The demographics alone means that this is going to be a question of increasing importance for the society. 

Second, I do think that there is a way in which this Council, given its predilections, does not simply treat ethical questions as merely technical questions, has a way of doing exactly what Rebecca has suggested, to lift up to view and show the limitations of what has been a kind of bureaucratic and technological, technical solution to these very complicated human questions.

Third, if you can take up the end- of- life decisions not just as end- of- life decisions but as part of a larger investigation of the questions about old age and some of their disturbing features and the human implications of those, we would put what is for many people the only question, mainly "When do you pull the plug?" into the larger, richer, and important medical and human context in which these decisions find themselves. I think we can do that.  I think we could show how to think about those questions in a larger context.

So I think we would have all of that richness about which Gil has spoken as well as an opportunity to do something useful, socially important.  And if we are divided on these matters, we will be able to present the best possible arguments on the various sides of these matters for the public discussion because if we're divided on things, people are divided.  I think that is perfectly all right.

Please.

PROF. GEORGE:  I think it is entirely possible that we could issue a report that would be very much along the lines of the human dignity and human cloning report, in which the Council recommended by a vote of 10 to 7 in this case a 4- year moratorium on physician- assisted suicide with the 10 breaking down into 7 to 3 within that camp as to why this is the case and the 7 breaking down to 4 to 3.

So I think there would be inevitably a fracturing here.  Now, that's fine if people think that that is a good way for the Council to proceed because we've got the best arguments out there and so forth.  And we're happy to do it again.  Then that's fine.  But if we're looking for a consensus approach to things or a consensus document, I don't think this will be it.

DR. KRAUTHAMMER:  I don't know why you assume it will be 10 to 7 or even split.

PROF. GEORGE:  I am not prejudging what the vote would be.

CHAIRMAN KASS:  Gil?

DR. KRAUTHAMMER:  I honestly don't know.

PROF. MEILAENDER:  I still think this is a good topic, and I would like to see us do it.  I do think Robby is right about the essential point.  I mean, you couldn't have read the bioethics literature for the last quarter century and not see that there are close connections between the way certain issues about personal identity get raised in the beginning- of- life and end- of- life questions.

So that will come up.  And we shouldn't take the subject up supposing that it won't do that.  It will do that.  That for me is not a reason not to take it up.  It's in some respects a reason to take it up.  I'm not a big devotee of consensus documents anyway.

So I think it is a good topic.  It's a rich topic.  But the notion that — we shouldn't deceive ourselves into supposing that what you decide about some of those end- of- life issues doesn't spin off in ways that have implications for what you might think about the beginning- of- life issues.

CHAIRMAN KASS:  Could I ask the medical people on this — I don't want to suggest that we start talking about things that have medical implications — whether this makes sense to the three of you?

DR. McHUGH:  I also have written on this subject.  I would welcome further discussion, but I agree absolutely with Robby that the responses are out there in relationship particularly to assisted suicide.

People seem unpersuaded by my prose, and they're not persuaded by your prose, which is even better than mine, that this Oregon exists out there in its world.  It would be useful to bring out, for example, in the Oregon experience that they promised that this was going to be an experiment and now won't let us look at the data.

I would love to have that out in the public arena that the Oregon group said that assisted suicide would be something we could do and learn from their experience as to whether it was a good thing or a bad thing and then when others of us came forward and say, "Okay.  Let us look at the data," then they would say, "No.  That's private."  I would be very happy to have that kind of information presented further to the American public so that they could hold the line.

I agree with Robby that —

CHAIRMAN KASS:  Both of you have chosen a way to narrow the question to assisted suicide and euthanasia; whereas, the staff has deliberately framed this question in a much larger context.  And Alfonso has spoken to that, Rebecca has spoken to that, Gil has spoken to that.

PROF. GEORGE:  Leon, I explicitly said that when it comes to those dimensions of the proposal, you wouldn't have this problem.  But the proposal does include these dimensions having to do with these very controversial and divisive issues as well.

I just worry about us running up against the situation where at the end of the day, we just say, "On these issues, we just have fundamental value differences, and we can't get past them.  We're at an impasse, and we just have to live with that" unless we think that getting the best arguments out on the competing sides is a real contribution, which you suggested and I don't doubt.

In that case, we will do it, but we should be prepared in advance, I think, not to at the end of the day, then, find ourselves trying to put together a consensus where one doesn't exist.  I think we need to in advance say we're prepared to do this other —

CHAIRMAN KASS:  In the executive order, it says that we are not to be driven by an overriding need to produce consensus.  We have taken it where we found it.  And where we don't have it, we do the President a service and the nation a service by making the best cases we can.  We may not have done it as well as we should, but I wouldn't be embarrassed by it and I hope no one here would be, really.

Dan, do you want to say something on this for the medical side?

DR. FOSTER:  No, I don't.  I think that there are many issues that have already been mentioned.  We mentioned care.  And I think that Rebecca is absolutely right.  In individual cases, even if you have got an advanced directive, — we go through this all the time — then families withdraw and argue about it.

I mean, the guidelines are all there.  There's not too much issue about meaningful life at that point.  But, as Charles said, you go through these cycles.  And you have to do it.  It's very complicated.

We are probably going to have to put into any discussion of the care of the elderly here the economic consequences, which are really huge, and to how are we going to care for these people.  I mean, even if you have somebody in a nursing home and so forth, the expenses are way above what ordinary people make right now anyway.  They just can't pay it.

So that may be one of the most important issues that comes up, a statement about the commitment of the nation to care for its elderly and helpless at that point.  I think that would be a very large part of it.

I also think that the issue of the suicide — we don't have time to talk about that now.  I mean, it will doubtless come up, but I would certainly hate to make that the major issue that was there.

I would be more inclined for the bioethics of the care if all of us, as we have heard multiple times, were once an embryo and all of us once upon a time will have been old and are going to die.  So I think that that is something that is very important: is the economic domains here.

CHAIRMAN KASS:  I would second that in its entirety.  Are we okay on this topic?  It looks like this is an area also worth developing to the next stage, trying to articulate the pieces of this better, find the people to come in, something on the economics of the health care of the elderly.  There are some people working on this.  They're befuddled.  We'll find out who they are and bring them in.

Other topics?  Mary Ann?

PROF. GLENDON:  This is really just another way of looking at the questions relating to the care of the elderly.  I think that's a great subject for us.  But I would be sad to see it separated from two of the other items that are listed here:  number 2, children; and number 9, the distribution of health resources.

One of the reasons I think that we would have a great contribution to make if we kept those three topics together is plain.  If you saw the front page article in The New York Times on January 8, it tells us more of what we already know.  Spending on health rose to a record level.  Health care spending accounts for nearly 15 percent of the nation's economy, and not only the largest share on record here but a larger share of the national resources than is spent by any other country.  Yet, we have this paradox that we know that we spend more on health care than any other country, but somehow there are great gaps in access to health care.

It seems to me with our emphasis in our reader and elsewhere on the relationships among generations, what it means to be human has something to do with our past and our future.  It seems to me that if we could keep these three topics together, we could help to overcome what I perceive as the dominant paradigm for discussing these issues today in our society, which is one of conflict between generations.

It seems to me you don't hear anybody saying that the elderly have a stake in the future and that all of us have a stake in how we treat those who came before us and gave us what we have.  So I like all the topics that have been proposed so far, but I would like to see a comprehensive approach to the elder care one.

CHAIRMAN KASS:  Any further comments in response to Mary Ann, who has given us two additions?  Michael?

PROF. SANDEL:  Mary Ann has been a tireless advocate of the ideas of the priorities in health care spending, both domestically and also internationally.  The footnote mentioned the point that was contained in the "Beyond Therapy" about the spending on baldness remedies versus malaria.

I think every time Mary Ann has brought that up, I've said I endorse it.  I realize it is not the most popular topic for many people here and maybe feeling that this Council isn't well- suited to take it up, but I think I agree with the point Mary Ann has made on a number of occasions, that if we look at the impact and the significance of the questions in a very practical way that we're dealing with, this would certainly rank among them.

CHAIRMAN KASS:  Bill May?

DR. MAY:  Behind the issue lies the question of the status of health care as good.  Is it an optional commodity?  And, therefore, the problem of access is not an acute problem.  But if you think of it as really a fundamental good, then access to that good becomes very important to sustaining a community.  And specifically, as you have suggested, the relationship of the generations to one another.

And the other issue is not simply the question of access but the comprehensiveness of this system, the degree to which it is not simply lopsidedly directed to acute care but to other forms of service that touch on the question of not simply death with dignity but aging with dignity, not that we can guarantee dignity and age by an adequate comprehensive range of services.  "Everyday" is a word that is used here.  But we can offer assistance in sustaining a life with dignity in the middle of aging.

I guess my question about that topic is whether this particular group is equipped to approach these issues.  It would require if you're dealing with the systemic issues, you have to think through.  Economists and others would need to be brought to the table to address these issues.

As a group around this table, well, oftentimes we have tried to compensate for our deficiencies here by bringing in guests, but there would be an awful lot of homework to be done on this issue if it became central to the focus of this Council.

CHAIRMAN KASS:  Paul?

DR. McHUGH:  I would like to support Mary Ann's suggestion very much because I think this interface, these interactions of these three themes are terribly important and carry with them a little bit of what she was saying that I want to underline, namely the development of our attitudes towards our responsibilities towards others, that there are often hidden agendas that are proposed for us, sometimes economic agendas, other kinds of agendas related to pain, and may, in fact, corrupt our attitudes if we don't put them out and show them in relationship to other values that we are committed to.  So I would very much support what Mary Ann is saying.

DR. FOSTER:  The only issue that is worrisome would be if we are studying all of life, it may be so big that you couldn't possibly do it in the two years that you've got.  So I am more inclined to focus on, to me, the more acute problem of the geriatric age group.  If we had time to add the children and economics, we are not going to solve that.  The Institute of Medicine has just had a new report out on health care and so forth.  But we could at least say that these are things, not solutions to it, but these have to be addressed.

So I would rather do some smaller thing well than to try to cover everything in a sort of superficial manner.  It is not to say that it is not critically important.  And they are all related, but I do worry about that.

CHAIRMAN KASS:  Frank?

PROF. FUKUYAMA:  I guess I still don't understand what this topic is.  Maybe Mary Ann could just explain a little bit more what you propose because if it is the resource allocation issue, then it does seem to be the broader national health policy debate, which is just such an unbelievable complex morass that I kind of agree with Bill that it is hard to see how we could get into that usefully.  Maybe you had something more focused in mind.

PROF. GLENDON:  I am not sure that I can outline an agenda for the group, but I think the precise area that we ought to focus on is the way in which this problem is currently articulated as one of conflict between the generations for scarce resources, rather than exploring the possibilities of, for example, as some European countries do, encouraging and helping with family home care, rather than policies that, whether inadvertently or not, push people into institutional care; the whole question of care- giving, who provides it and how we value it in a society.  Take a look at why health care at the end of the life is so expensive and what that means.  I think right now all you can say is there is a problem with thinking about this area of elder care separately from other areas because it fuels the conflict model.

CHAIRMAN KASS:  Anything further on this?  Anyone want to say anything more on the children side of this?  We have talked more about the medical resources question.  Janet, please.

DR. ROWLEY:  I was just going to make the comment that to the extent that we discuss what is known about the developing human brain and both the pattern in which it develops and how we as a society could foster the full development of those potentials in all children, we then could be focusing on an extraordinarily important component of what children really need, both educationally and in terms of home nurturing and health, so that some of those topics could be brought up.

CHAIRMAN KASS:  That is very nice.  Again, I don't think we can do everything and hope to do anything well.  We have to make some choices, but we can I think put our toe in the water on a number of things and see where it goes.

I do think that I would second Mary Ann's suggestion that one doesn't want to contribute to the conception of a society that is advanced by the AARP, in which by the time you are age 50, you declare a war upon everybody who is younger and simply look out for yourself.

Yes, we have obligations.  I never joined.  It offended me.  Yes, we have to look out.  And we have obligations to our elderly population and the duties of care rooted in obligation and love and justice, but in many ways, the state of our children is perhaps even worse, arguably.

To have started in, we got a little entrance into this in what we looked at with psychopharmacology and children.  We concentrated more on the beyond therapy uses, but one should be I think even more impressed with the need for therapy on the part of a growing number of children.

It was reported to us I think, as this was shared here, that among the entering class at one of the elite universities this fall, 20 percent of the entering class was on or had been on antidepressants.  That's not just better diagnosis, I'm fairly confident.

It seems to me that if we could lift up not just the technical questions of childhood but maybe beginning in the way Janet suggests with the development studies and call attention to the questions of bioethics in children generally, even if we do it on a well- focused topic, I think that would be great.  Plus, that's, once again, not to reduce these questions to their most narrow and technical formulation.  We have the capacity and the desire and I think the experience to do something like that.

I know a couple of people have to leave about 11:30.  If they want to put their oar in for one of the other topics before they have to go, I give them the mike.  Michael?  Dan?  Anything you would like to take up, Mike?

DR. GAZZANIGA:  It touches on all of these things.  I don't know if it requires a separate category or not, but I am intrigued with the problem of the overselling of medicine in our culture.  I think that is what is bankrupting everything.

It is a very complex problem.  People have tried to address it, but the vested interest in sustaining boutique medicine, serious medicine gets so intertwined that you can't separate out the good from the bad.

Epidemiological studies are carried out which show that a certain procedure shouldn't be undertaken.  And, yet, it continues.  It costs billions of dollars every year.

To have a very thoughtful effort of healthy economists coming in, of physicians who have insight into this, who have thought about it, I can't help but believe would be highly educational.

Everybody just assumes that every new little trick in medicine isn't right.  With that comes this bankrupting influence.  It is ruining institutions of higher education.  We can't afford these bills.  No one can.  Everybody has got the same problem.  And they solve it by just cutting things off wholesale and not really analyzing the underlying problem.

So I don't know if there is a place for national conversation on the overselling of medicine, but I think it is something that ought to be considered by somebody.

CHAIRMAN KASS:  Thank you.  We had talked, you and I, Mike, and we had Dr. Fisher come down and talk to the staff.  It may fit, really, with the resource question.  And it might fit also with our earlier concerns about medicalization as fueled conceptually as well as economically and sociologically.  Maybe we should get Dr. Fisher to come down and address the Council as a whole.  He has done some very interesting work along these lines.

Anything further on the list of possible topics?  Bill?

DR. HURLBUT:  Gil has spoken to the importance of dealing with practical issues of immediate concern.  As difficult as it is, I think given the stage of science we are at, we need to continue the dialogue on the issues raised in item 7, boundaries of the human, because the Dickey amendment and several other recently launched legislative proposals relating to issues from patenting of humans to cloning and so forth use the terms "embryo," "organism," and specifically "human organism."

I think somebody ultimately is going to have to define what those terms mean because science will be very creative in finding ways to produce ambiguous entities that may hold out profound possibilities for progress and not actually evoke the moral concerns that are associated with in some people's mind the moral standing of the embryo.

I think in order to open the future possibilities in the whole range of science, as we have discussed, all the way from assisted reproductive technologies, which certainly we will want to study the fertilization process, all the way up to uses of developmental trajectories that will be engaged in regenerative medicine, we are going to have to discuss, somebody is going to have to discuss, the meaning of human- animal chimeras, the definitions and significance of categories of natural kinds, the generation of human parts, the parts from wholes.  Certainly as we move from genomic and proteomics, now on to developmental biology as a major focus of the advance in science, we are going to want to study embryogenesis.  We need to try to find ways this can be done with moral consensus.  To do that, I think we need to address the question of what is the minimal criterion of the human organism?

Robby mentioned yesterday some suggestions that I and others have made for the possible production or procurement of embryonic stem cells through entities that are not necessarily entities with moral status.

I think that we need to address these issues.  I know they are conflicted issues, but, on the other hand, we have an opportunity as a Council to do something that no other council will ever have the chance to do.  And that is at this early stage of the advancement of these particular sciences, we can address, we can frame the terms of discourse, define the terms of importance, and work to defend human dignity while we open the science.

I personally feel as though we could make a great contribution on that level and do something that does more than define dangers but actually opens up positive possibilities; in other words, a very constructive dialogue.

I know that won't be an easy conversation, but I think it takes us beyond the issue of the conflict over the inviolability of human life to an effort to find consensus on important issues that relate to other secondary issues of moral concern regarding obligations to nurture, defense of integrity, affirmation of significant boundaries and transitions, definitions of what an organism actually is and what a human organism actually is.  If we don't do it, I personally think we are failing in our opportunities and our mandate.

So I feel very strongly personally about addressing the issues in item 7.  I just feel like it's thrust upon us and we should greet it.

CHAIRMAN KASS:  Frank?

PROF. FUKUYAMA:  I support Bill in this for the reasons he gave.  For example, in our work, in my work and in your work, we use the term "human dignity" all the time and "threats to human dignity" or "assaults on human dignity."  Now, I have my own definition of what that is, but it's probably not the same as yours.  And I don't think that we as a Council have really grappled with trying to come to some kind of consensus about what the essential characteristics of our shared humanity are that we need to defend.

In fact, that very word is becoming increasingly politicized because the Europeans use it a lot.  I know there are a lot of Americans who said, "Well, this is just Euro- speak for people who want to restrict technology, and it actually has no substantive meaning."

I think AAAS or some body in town actually just had a conference on the concept of human dignity to try to unpack the various meanings of that, but it's not just a lexicological issue.  It's really a substantive issue about what we think ought to fill that particular container.

CHAIRMAN KASS:  All right.  Let me make a procedural comment.  We have got some support for a number of important things here.  I think I know what some of the next steps would be on some of them, I think on some of these others, perhaps this last exchange...

By the way, the Council has come under attack for its use of the term "human dignity" in the bioethics community, "empty slogan."  We have an obligation to try to fill out something of what we mean here.

The staff had actually its first session.  And we mean to make it our own business to try to figure out what in the world we are talking about when we talk this way.  In particular, if you are going to talk about the dignity of human procreation, you had better know what you are talking about. So we are going to do some of that in- house.  I think the boundary questions that Bill raises are an important manifestation of that.  I think we are going to have to turn to some individuals here and ask you to draft some things.  The staff can't simply write on every one of these topics.  I am fairly confident that, Bill, I will turn to you, and Mary Ann for some help elaborating some materials that the rest of us can read.

I am very encouraged by the discussion.  I think we have settled on moving the ball forward on a number of very large, all of them important topics.  There is probably more here that we can do well, but we have got enough encouragement from this discussion to begin to take the next steps and plan for what promises I think to be a very interesting and I hope fruitful next term.

We have run a little bit over, but we are now at the time for public comments.  We have four people who have asked to make a public comment.  If the Council members wouldn't mind simply not taking a break, we will go directly to the public comments.  We will probably adjourn close to noon.

The first guest, Pamela Madsen, is the Director of the American Infertility Association.  Pam, welcome.  Nice to have you with us.

MS. MADSEN:  Thank you for having me.

SESSION 7:  PUBLIC COMMENTS

MS. MADSEN:  Once again, it is my honor to come before the President's Council on Bioethics as the Executive Director of the American Infertility Association, one of the nation's preeminent infertility patient advocacy organizations.

I am especially pleased to extend our thanks for your genuine receptivity to the members of our community.  We would like to acknowledge and applaud the authentic discourse you have engaged in with constituents of reproductive medicine from patient groups, such as the American Infertility Association and RESOLVE, to medical professional organizations, such as the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology.

The extent to which the outcomes of such conversations are reflected in the new draft recommendations on biotechnology and public policy is an encouraging sign of cooperation between the government and those it serves.

We are pleased to see some of the most onerous provisions, such as government tracking of each embryo created in vitro, have been removed.  We are relieved that the Council has clarified its position with regard to third party family- building options, such as leaving the decision to pursue embryo or gamete donation or gestational surrogacy to the individual.

The American Infertility Association is gratified that the Council has dropped its call for federal monitoring of our children through the first year, avoiding what would be a de facto compulsory registry.  Instead, the Council's calling for nongovernmental outcome studies, such as the American Infertility Association's recently launched prospective study, Footsteps:  The IVF Children's Health study.

Participation in the AIA study is going to be purely voluntary.  Selection bias should be minimized, if not eliminated, by enrolling women in the first trimester of an ART pregnancy.  We will have a control group, which for the first time will be other infertile couples who have conceived through intra-uterine injection.  So we will be able to really look at the IVF technology, which is so important.

In fact, patients are comforted that the Council's modified draft explicitly states that participation in all federal studies will be voluntary, which you know we support.

While the Council's recommendation to report data on the cost of ART to patients as well as a number of ART patients stirred controversy, the AIA believes that these really could be useful measures.  Our concern, as always, is that the information gathering does not impinge on individual privacy and that the data are presented in a consumer- useful context.

The Council has made moves in the right direction on these issues.  Further, the AIA is delighted to see that in this incarnation, the draft recommendations call for a more uniform, user- friendly informed patient consent forms as well as an internal review board- like body at each center that uses experimental technologies in the treatment of infertility.

We also wish to acknowledge the Council's advance towards a more open dialogue by dropping some of the more ideologically loaded language that laced the initial draft.  We are so pleased that the Council refers to an embryo as an "embryo" and not as a "child to be" or "future child."  The gesture has profound consequences, but we believe that it does not go far enough.  We would be happy to see even more of that removed.

To call a pregnancy resulting from sexual intercourse "natural conception" implies that there is something unnatural about assisted conception.  As I said before, my kids are 100 percent biological and natural at all times.

The infertile are, as I said before, lucky to have kids.  We don't want to see any of this language about natural/unnatural kids in there.  It does affect how our children are perceived.  Language is very powerful.

We encourage the Council to continue to review its language, recognizing that it has a lasting effect on the social and political environment and the lives of thousands.  There is one element conspicuously missing from this draft, and that is a recommendation for mandated coverage of infertility treatment.  We believe that insurance would solve a host of problems.  And we hope that the Council would put its considerable muscle behind an insurance initiative.

When you call my doctors an "industry," you only are calling them an industry because we are not covered by health care.  So language is important.  And language will be changed by social policy to just caring for the infertile people as patients and our doctors as our care- givers.  Please don't call it "industry."  When we are patients in treatment, we see our doctors.  We are not going to Ford.

Again, the American Infertility Association extends its gratitude to the Council for the opportunity to be heard and to have its concerns and suggestions treated with a great deal of respect.  We look forward to continue to work together, heartfelt thanks.

CHAIRMAN KASS:  Thank you very much.

Ordinarily I wouldn't respond, but I do want to say that that language "child to be" never meant anything other than what it now says it is.  We were struggling for a way to talk about effects on children born with this procedure, which effects are produced at a time when the children are not yet born.  It was a complete misunderstanding to say that that was meant to be an embryo in that discussion.  And that was clarified I think with everybody long ago.

Thank you very much.  I am also not pleased with the reference to this as an "industry."  And that will come out.  I have never liked it.

The next comment is from Sean Tipton of the ASRM.  Excuse me.  Do you want to comment?

PROF. MEILAENDER:  I would like to make a brief comment if that's okay.

CHAIRMAN KASS:  Please.

PROF. MEILAENDER:  I simply wanted to note it's a bit churlish to have someone thank you and then to not quite take the thanks, but it's my understanding that we haven't reached any final deliberation about some of the items that Ms. Madsen mentioned and whether they will or will not appear in whatever final report we bring about.  So I simply want to note that I don't think we are at the end stage of our deliberations.

CHAIRMAN KASS:  Sean Tipton, welcome back.

MR. TIPTON:  Thanks a lot.  I really just wanted to thank the members of the Council and Chairman Kass and the staff for the opportunity that we have had for input.  We hope that the report is at least better informed than it would have been otherwise.

I am so used to not needing microphones I always forget people have to worry about taping and things.

There is certainly a lot that we like in the report.  Predictably and perhaps appropriately, we don't like everything in the report as it exists.  I do want to talk a little about the question of including the data on the health of the children at one year out in the registry because I think that what is important to consider is the question of quantity versus quality of that data because I think that if you put the one- year health outcomes in the registry, you will have a nice data point on what will probably be the 50,000 children born every year by the time that gets implemented.

However, I am not sure the quality of that data is going to be very good because in the real world, it is not clear how that data is going to be collected.  Will it be the reproductive endocrinologists calling somebody in the infertility clinic, calling the parent, saying, "How is your kid?"

Probably the best you can hope for is a form going to the pediatrician's office, having dealt with all the privacy concerns to make everything HIPAA- compliant.  Then you will get an administrative person in the pediatrician's office who is going to go through and flip through a chart and see if there is anything really big written there.

So I am not sure that the quality of that data is going to be really good.  You would have tremendous reliability issues between the assessments of those children.  I think in terms of what I think you want to get, which is a question, being able to address the question of the safety of the circumstances of the conception on the children subsequently, I think you would be far better off getting that data through a carefully designed prospective study.  So I think you need to consider that question.

We appreciate the thoughts that the Council has given us on the behavior of the field and of our organization as a representative of the field.  We have chosen and are proud of the role we have played, being primarily educational and a standard- setter.  We have not been generally a punitive sort of organization.  The question of to what extent that needs to change or to be added in is something that is under considerable discussion within our membership and our leadership.  So we really do thank you for your thoughts on that.

Now, I am positive if we brought 15 infertility physicians in here and asked them if they had some thoughts around how the bioethics community should behave, they would probably have some ideas.  I am not sure that they would be as carefully considered as what you have offered us, but it is worth talking about.

Finally, I do want to talk about I think inadvertently I fear that you are contributing to a problem.  And that is the perception of commodification of reproduction and of reproductive materials.  I think by calling for a collection of charges to be included in the registry, I think that is a very different creature than a question of how often what technique is used and why and what the outcomes were.  I think by collecting charges, I guess I would ask for a little more attention to why you think that is important to be included and what that contributes other than satisfying some curiosity.

We would agree that would be interesting to know.  We have had some concerns about our own ability to collect that for a restraint of trade issues.  So I think that is an important question.

I would agree — and I appreciate Dr. Kass' support in terms of a question of the characterization of this field of medicine as the infertility industry.  It actually doesn't appear very often in the report, but those words are heard constantly around the table.  That may be by design, and that may be by intent.  Obviously, then, that is fine.

I think if you were to go this morning and we could look and see what is happening in infertility clinics around this country, you would see patients and their partners seeing physicians and allied health professionals trying to overcome a medical problem.  You would not see natural resources inputs trying to manufacture products.  We certainly don't see it that way.  The patients don't see it that way.  And we would ask for it not to be described in that way.

CHAIRMAN KASS:  Thank you very much.  It was very nice to see you this morning in the Washington Post.

Susan Poland has the last public comment.  Welcome back.

MS. POLAND:  It's still morning.  Thank you.  Good morning.  I am again speaking as a private citizen but building on my experience with an IVF lab and doing basic research, working at the Kennedy Institute for 20- some years and reading Bioethics and also with my legal background.

I don't have a prepared statement.  So forgive me.

I was struck yesterday by the comment about the one- year monitoring of children born with reproductive technologies.  My comment really is very short.  I would like you to consider oversight of a genetic technology, not a reproductive technology.

The one- year term, if I were an IVF patient, type A, a movie star or somebody, I would be very intimidated by the fact that you want to monitor how I am taking care of a child.

If I were a doctor or an ob- gyn, I would think, "Oh, my God.  How are they going to sort out the trauma of disease or anything caused by birth with what might have been caused at the formation of the genome?" or if I were a vaccine doctor, someone there.  So there are a lot of things that can happen in that one year.

I would suggest that you look at maybe getting a genetic sample, just like you do with blood for PKU.  It is very easy I think to sell to someone saying, "We're looking at the technique, not you.  This is going to be anonymous, not anonymized."  It just goes back through to the federal government, which will verify that there was a live birth from this clinic of a healthy baby and then look at that genome to compare it with other genomes.

And on the fact that it is a genetic technology, it is regarding the making of a human genome, not the mapping of one, but it could be done already under the guise of what is at NIH now, whether the Human Genome Institute or the National Human Genome Project.

So I think the problem is one of words, the term "assisted reproductive technologies" became a term after IVF.  And it went back in time to include artificial insemination by donor and husband.  I again say it's not the third party element, but it's the third party plus the extra- corporeal fertilization that we're concerned with.

I also think, lastly, that the public actually needs to benefit.  This has been a relationship going on between private parties, patients, and physicians for a long time.  And with the rise of genetic or passing of viruses from animals to human and then human to human,- - whether it's SARS or through Mad Cow, which we call BSE; and then Jacob- Kreutzfeld,-- in the long run, we might have had more information about how these diseases work if we had been watching how genomes and the human genome work and interact in comparison to animal.

Thank you.

CHAIRMAN KASS:  Thank you very much.

I realize I have made a mistake and owe an apology to Erin Kramer.  My bifocals missed the line.  Erin Kramer from RESOLVE.  Welcome back to you.

MS. KRAMER:  Thank you.  Thank you for the opportunity to comment.  I am here on behalf of RESOLVE, and we appreciate the opportunity.

First, I want to address the media advisory that we issued a couple of days ago as I understand that it struck some members of the Council negatively.

I just want to have you understand that a committee of individuals who are part of RESOLVE have spent a considerable amount of time, a great deal of time looking at the various drafts that the Council has put forth as well as the overview of the ART document.  And it was from those drafts that we have felt that infertile patients would be adversely impacted.

In our media advisory, we hope we tried to make clear; in fact, we thought we made clear, that the comments, that the concerns that were listed there were about the previous draft, not about the draft that was issued yesterday.

Understandably, though, we apologize for the timing of that release.  And perhaps the timing could have been different.  But it really was meant to address the earlier drafts and the concern we had about the way the proposals were written in the earlier drafts.

Having looked at the new draft of the proposals, actually, we were quite pleased about the changes that were made and appreciate the fact that we have had the opportunity to meet with the Council and the staff and to let them know where there might have been ambiguities and where we think that some of the most potential problems might arise.  So we are very pleased that those considerations were taken and that changes were made.

We are pleased that the issue has been set aside, at least in this draft, of the mandatory government tracking of untransferred embryos.  We do think it is preferable to gather data on outcomes for children with a longitudinal study, gathering information that way, as opposed to a new mandatory reporting system that would involve layers of doctors, which we think is very unworkable.  We do appreciate the voluntary nature that is now in the draft of the participation in these things.  So we are quite pleased with that.

We do agree with some of the comments that were made yesterday by Janet Rowley, though, that some of the concerns in this medical area could be addressed by policies that recognize the link between the lack of insurance coverage and the potential for adverse outcomes in births.  So we would like to see more of that language in there.

As a broad matter, we do appreciate very much the opportunity that the patient advocates have had here and trust that that will continue.  When this document that you create goes before Congress, we also hope that we will have that same equal opportunity there.  We think the patient voice should be very prominent in these discussions.

Thank you.

CHAIRMAN KASS:  Thank you very much.  And thanks to all of the public commenters this morning.

Please, Mary Ann.

PROF. GLENDON:  Yes.  While we are handing out thanks this morning, I would like to thank the speakers because it is always so interesting for a citizen to see how the lobbying process works.

I also want to express thanks for the correction of using the term "industry" because technically that is not quite the right term for this profit making- business.  I won't use it again.

Thank you.

CHAIRMAN KASS:  Let me say just a funny little word in relation — because all of the speakers came forth to really speak about the forthcoming report on biotechnology and public policy and that area.  We obviously made some kind of an error early on, despite the fact that we said repeatedly in our discussions that we were not here interested in taking on the profession of assisted reproductive technologies.  In fact, our only interest in reviewing that activity was this is the gateway, this is the gateway technology to the adjunct technologies that are coming based on genomic knowledge and that if you are thinking about the regulatory and monitoring process overall looking to the future, you have to start by knowing where you are here.

Where we are here is only in this area of assisted reproduction with a few little wrinkles being added in.  We began a diagnostic document on how is this current practice is monitored, overseen, and regulated.  Somehow, despite our repeated insistence that infertility patients, we were not trying to get in the way of their receiving treatment, we were not trying to police the profession of assisted reproductive technologies, we must have sent the wrong signals or you people must be simply nervous or my reputation, which preceded me, has not been allowed to be judged on the basis of what people have seen here.

But I am very glad that as a result of the extensive conversations that we have had with RESOLVE, with ASRM, and with the American Infertility Association, that I hope at least that the perception of our intentions and the spirit of this inquiry have been clarified and that while we will continue to disagree about this, that, or the other, it ought to be clear that those disagreements do not rest upon those grounds that we have sometimes been accused of holding.

People's perceptions will continue to be what they are, but I welcome this morning's comments as a kind of not exactly a love fest.  We still probably have our differences, but at least I think we understand each other better.  And I would like to express my gratitude for the generosity of spirit of the comments that have been made to acknowledge that fact.

So thanks to all of you, both for what you have done before, for what you have brought yourself to say here publicly this morning.  And there obviously will be opportunities for us to continue to work together and correct, continue to correct, misimpressions and misperceptions of the things we are interested in.  So thanks.  Thanks for today and for what went before today.

Last- minute words?

(No response.)

CHAIRMAN KASS:  Go in good health.  Be well.  We will see each other in April unless there is an emergency meeting.  There is a date on the calendar.  I don't remember what it is.  But we are unlikely to be emerged.

(Whereupon, at 11:58 a.m., the foregoing matter was adjourned.)


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