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Meeting Transcript
June 28, 2007


COUNCIL MEMBERS PRESENT


Edmund Pellegrino, M.D., Chairman
Georgetown University

Benjamin S. Carson, Sr., M.D.
Johns Hopkins Medical Institutions

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

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

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

Alfonso Gómez-Lobo, Dr.phil.
Georgetown University

William B. Hurlbut, M.D.
Stanford University

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

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

Gilbert C. Meilaender, Ph.D.
Valparaiso University

Carl E. Schneider, J.D.
University of Michigan



INDEX

SESSION 1: THE HEALING PROFESSIONS

CHAIRMAN PELLEGRINO:  Good morning, good morning, good morning.  Welcome to the members of the Council, the 29th meeting of the President's Council on Bioethics.

I want to welcome our guests as well.  We are in slight violation of my usual rule to start precisely on time, but we've had some difficulties with travel.  The weather is awful all over the country, and some of our initial speakers, as luck would have it, have not been able to make it right away.

So we will turn the agenda around just a little bit, and instead of having William Sullivan, who is stranded somewhere — where is he? — Chicago, and we're hoping he will get here this afternoon, but Dr. Relman has graciously agreed to be the first speaker, and our second speaker also has graciously agreed to the change in schedule.

I'm going to ask Dr. Lisa Day to open the program, if you wouldn't mind.  She has graciously undertaken the task because Dr. Patricia Benner was not able to come, and that was decided at the very last minute.  I want to thank you most sincerely for picking up the ball so rapidly and moving ahead.

It's customary in these meetings not to go into an extended discussion of the background of the speakers.  You have the essential facts in the program, and so I will not say anything further  than to introduce Dr. Day as Associate Clinical Professor at the University of California, San Francisco, in nursing, and you are, I believe, an Associate and a student as well of Patricia Benner's; is that correct?

DR. DAY:  Yes, indeed.

CHAIRMAN PELLEGRINO:  But you, of course, will be speaking on your own and giving your ideas on the question of the healing professions.

Just a word, and I don't want to keep you standing there long expectantly.  On the program this morning and tomorrow and tomorrow afternoon, we are opening up several new topics for the Council.  This is a consequence of previous surveys we've made of Council members and what their interests are and especially of individual conversations.

And people have expressed repeated interest in some of these problems, but we are not dedicated necessarily to taking up these issues unless it is the wish of the Council.  So this in some ways is exploratory.

The healing professions is a question you all know that's very much before all of us, the public, the academicians, the questions of professionalism, the questions of what has happened, if anything has happened, to the classical professions of medicine and nursing and ministry and the law.

We will be focusing on the healing professions, medicine, nursing, allied health, all of those that have direct confrontation with human beings who are in need or dependent and vulnerable, and the way in which we approach them and what our obligations are, particularly from a moral point of view, as well as sociological will be the focus of these presentations.

Without further ado then, Dr. Day, may I ask you to address us?

DR. DAY:  Thank you.  Thank you very much.

I'm quite honored to be here, to be asked to represent nursing in this discussion of the professions in society and of professional practice and the ethics of professional practice, and I'm honored to be here representing Patricia Benner, who is my mentor and teacher, and also to be representing my practice, which I'm very honored to have been a nurse since 1984 when I graduated with an Associate degree.

And in this discussion of practice ethics, nurses are directly engaged in and embody everyday ethics as they work with individuals, families, and communities.  In this presentation I want to take up two main themes.  First, I want to take up a consideration of practice ethics and what I think are the distinctive marks of nursing as a profession and as a practice, and then second, I want to discuss some of the impediments nurses face as they try to enact the goods of our practice.

So nursing as a profession and as a practice.  Nursing is a socially organized set of caring practices.  The practice demands that nurses develop concerns about how to meet, empower, protect, nurture and comfort those who are vulnerable and in need of care.  This is accomplished, in part, through advanced knowledge of nursing and medical therapies and also through practical skills that allow nurses to titrate these therapies according to particular patients' responses.

The margins between what is therapeutic and what is dangerous in this practice are often narrow, and the opportunities for errors in judgment are many, but the nurse when truest to her or his practice tradition does this work with an acknowledgement of the distinctiveness and separateness of the other and with the understanding that the need for care is universal and that we as helpers share in the same human possibilities and vulnerabilities as those we would like to help, we seek to help.

This stance is distinct from that of the technical expert who holds an external relationship to the object of craft or fabrication.  For nurses there is no durable product.  We're engaged in a process of relationship that Aristotle would describe as phronesis rather than techne.

The outcomes of our practice are not predictable, and we operate most often in under-determined situations that are changing constantly.

So the practice of nursing requires a knowledge base and rationality, but also embodied skill, know-how and ethical comportment.  Good nursing practice requires a commitment to a response-based ethic and depends on knowing the particular patient.  Nurses cannot coherently claim to apply a narrow rationality or technique that guarantees mastery over outcomes when good nursing practice really depends on caring relationships with concrete, finite and particular others.

The ethics of nursing practices inextricably connected to the daily clinical work that nurses take up.  Learning to be a good nurse requires one to develop not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 

So six aspects of skillful ethical comportment and clinical judgment are central to becoming an excellent practitioner.  First, the ability to link clinical and ethical reasoning.  So linking clinical concerns to a sense of the good.  What is good to our practice?

And then thinking and action and reasoning and transitions in this ever changing relationship that we form with patients and communities and families.  Nurses must develop response-based practice and a sense of their own agency in this practice.

In this view, ethical and clinical reasoning cannot be separated because the visions of what is good, bad or harmful dictates sound clinical judgments.  The moral sense of what is good to be and do in a situation guides problem identification, guides the selection of therapies and the evaluation strategies for those therapies.

So when we think about bioethics and health care ethics, we think often about procedural ethics and a justification of right actions, and a justification of right actions based on moral principles, while this is useful for institutional policies and procedures and for justifying ethical decisions in dilemma or quandary cases and also for insuring rights and justice, this type of ethics is not sufficient for discovering or enacting the good in concrete particular caring relationships, such as nurses make.

That nurses seek the good in situations of risk and vulnerability also requires more than a diagnostic armamentarium for fixing pathologies and deficits.  It requires that the good possibilities in actual concrete situations and concrete relationships be acknowledged and nurtured.

Nursing practice invites nurses to embody caring practices that meet, comfort, empower and advocate for vulnerable others.  Such a practice requires a commitment to meeting and helping the other in ways that liberate and strengthen and not in ways that impose the will of caregiver or impose dependency.

Helping that dominates, takes over or promises what is not feasible in an attempt to realize a static predetermined goal must be recognized as such and vigilantly resisted.  Notions of the good and ends of practice are essential to nursing.  Benner and colleagues have argued that clinical judgment cannot be separated from ethical reasoning because each clinical judgment is about what good is at stake and what to do in each particular situation.

If nurses do not have a good understanding of worthy ends in nursing practice, that is, goods internal to practice as MacIntyre would describe it, then their clinical judgment will be faulty, and likewise, if nurses do not have a good grasp of the science of pathophysiology and medical nursing interventions and therapies, then they can make neither good ethical nor good clinical decisions because they cannot know what is good to do in this particular situation.

So good nursing practice also minimally requires the following moral sources and skills.  First, relational skills that allow the nurse to meet the other in his or her particularity and to draw on the life manifestations of trust, mercy, and openness of speech.  So this requires nurses to develop communication skills and an appreciation for  and ability to engage in narrative interpretation and narrative understanding.

Nurses require the development of a perceptiveness in recognizing when a formal moral principle, such as justice, is at stake.  Nurses also require the development of skilled know-how that allows for appropriate action in particular encounters and allows for that to happen in a timely manner.  So nurses need to respond fairly quickly in certain circumstances.

Nurses need some skill at deliberation and communication skills that allow for thoughtful consideration and justification of actions and decisions and communicating among health care team members and communicating with patients and families.

Nurses require an understanding of the goals and ends of good nursing practice, and nurses are required to become participants in a practice community, and this will allow for character development of the individual and for the actualization and extension of good practice overall.

Practitioners will exercise distinct forms and qualities of moral judgment based on their relative knowledge and skills in these areas and based on the possibilities for practice that the community in which they are situated facilitates or impedes.

And next I'd like to take up the impediments to realizing and enacting good nursing practice.  So what stands in the way of us enacting the goods internal to our practice?

Well, first, the professional hierarchy in health care and the privileging of the biomedical model of disease and treatment.  Perhaps nowhere are crippling hierarchies and status inequities more evident than in health care sectors with the privileging of dense technology and the biomedical model over basic caring practices.  This dysfunctional arrangement shows up daily in nursing and doctoring practice as breakdowns in communication, medical error and in the current safety crisis in hospitals.

The concerns of nurses often take a back seat to medical diagnostics and treatments concerned with efficiently controlling diseases, and the institutions we practice in support this prioritization.  And although it is becoming more evident that medical interventions alone with little or no attention to basic human concerns, like the social well-being of individuals, families and communities or access to good nutrition, nature, exercise, and a safe environment, cannot produce sustainable good health.

Health care policy, economic and institutional structures are all set up best to support acute medical intervention for crises. 

This press for efficiency and cure in health care institutions is combined with a devaluing of the relational and caring practices of nurses, and institutional structures in many ways impede the best nursing practice.

Another impediment to best nursing practice is inadequate preparation of nurses.  Nursing education in many ways under-prepares nurses for the demands of practice.  Based on findings from our national nursing education study which has been conducted under the auspices of the Carnegie Foundation for the Advancement of Teaching, we conclude that there's a major under-education of nurses, given the complexity of medical nursing and biopsycho-social sciences.

For one thing, there are many different points of entry to professional practice as a registered nurse, and in the paper here, I had originally a slide which I decided to delete, but there are different degree types that allow one to enter practice as a registered nurse and become licensed in most states.  Most states will recognize an Associate degree, a diploma from a hospital-based school of nursing, a Bachelor's degree.

There are also second degree programs that are very popular now, and they're very much the cutting edge of new programs in nursing.  An accelerated Bachelor's degree for someone with a Bachelor's degree in another field; the accelerated Master's entry degree, these are all points of entry by which one might sit for licensing as a registered nurse and become a professional practicing nurse.

These multiple points of entry indicate disagreement over what education nursing practice requires.  The American Organization of Nurse Executives and the American Association of Colleges of Nursing have both called for a mandated baccalaureate degree as the point of entry to nursing practice.

The American Nurses Association first made this recommendation in 1965, but to date the profession has not had the will, the funds, or the political power to make this happen.  Each state legislature in this country seems to be strongly committed to their community college nursing programs, despite the fact that community colleges are under-funded for the very expensive, high faculty-student ratios required for nursing education and despite the fact that community colleges have not delivered on their promise of increasing the diversity of the nursing work force.

And although it seems like promoting a faster path to the R.N., such as a two-year Associate degree, should ease the nursing shortage by putting more nurses into practice more quickly, it is more likely to actually compound the nursing shortage.

First, the two-year Associate degree in nursing takes a minimum of three years and may be as long as four to five years to complete, and this has to do with difficulty getting into prerequisite classes, credit creep so that more and more credits are added to programs without adding more time.

But also at the root of the current nursing shortage is a serious shortage of nursing faculty, and this is the true root of the nursing shortage.  We've turned away hundreds of thousands of applicants, qualified applicants, to programs of nursing for lack of faculty, for lack of educational facility.

Given this shortage of nursing faculty, reliance on community college nursing programs compounds the faculty shortage since the Associate degree does not qualify the graduate to take up an academic position and only about 15 percent of these graduates go on to complete a baccalaureate.  Fewer still go on to complete graduate degrees.

Thus, the huge numbers of community college graduates in nursing create a faculty bottleneck that compounds rather than eases the nursing shortage.  But even more serious than this disagreement over the appropriate point of entry is the quality gaps in the educational preparation of nurses and in the teaching development of nursing faculty.  And this is across all programs.  So diploma, Associate degree, baccalaureate, and even second degree Master's entry and accelerated baccalaureate programs.

Nurses are under-educated for the current demands of the practice and for the demands of the increasingly complex health care delivery systems.  So confronting the complexity of health care and being able to engage in policy discussions to generate changes, nurses are not being prepared for this.

Patient safety and well-being depend on nurses adjudicating, titrating, and adjusting therapies according to individual responses.  Teaching this practice requires clinical expertise, as well as excellent teaching skills.

When faculty lack the ability adequately to prepare students for the transition to work, new nurses find themselves unable to engage in a practice that realizes the goods internal to it.

So for all of this bad news, the impediments to practice and struggles that nursing is having, there is also some remarkably good news from our national nursing study, and this is despite the difficulties of finding good sites for students to engage in hands-on learning.  Our clinical training tends to be excellent and safe.  Nursing students maintain a strong desire and passion to do a good job and are committed to engaging in an ongoing self-improving practice.

The nursing students demonstrate a strong connection to the goods internal to nursing practice.  They are concerned and they talk about concerns that the practice that they learn allow them to meet the patient as a person, allow them to preserve the dignity and personhood of each individual patient, allow them to respond appropriately to substandard practice and act as advocates to patients, families and communities.

Students and faculty in schools of nursing are seriously engaged in an attempt to do good nursing practice.  What impedes this possibility is the lack of rigorous scholarship demanded of nursing students in the social and natural sciences and in the humanities, and a lack of connection of these sciences and humanities to the practice of nursing, so teaching for a practice, particular discipline-specific pedogogies and teaching strategies to connect the science to the practice.

At best, we as nurses struggle in our practice to achieve the level of attentive, relational, clinical care we seek to provide the public.  Our health care institutions have not been designed adequately for good nursing nor for good medical practice, but rather for efficiency and profit.

Health care institutions often focus on profit and growth rather than on health promotion and healing.  Nursing, doctoring, and all of health care must move from a commodified, expensive, crisis- and cure-oriented system toward a focus on public health, health promotion, illness prevention, and management of chronic illness.  Without such a fundamental change we will continue to bankrupt our economy and do little to improve the health of our citizens and communities.

A good society should provide its citizens with access to health and health care as a right.  Anything less diminishes the quality of our lives together.

Thank you.

(Applause.)

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Day.  Again, thank you for coming on such short notice, hopping on the plane in this emergency.  Thank you.

DR. DAY:  Yes.

CHAIRMAN PELLEGRINO:  Dr. Rebecca Dresser, a member of our Council, will open the discussion, and you and she can respond to whatever questions may arise.

DR. DAY:  Thank you.

CHAIRMAN PELLEGRINO:  Rebecca.

PROF. DRESSER:  Well, thank you.  That was very impressive for someone who had to step in at the last moment.

When I was asked to do this, I thought, well, I don't really know much about nursing.  I haven't taught students or written about it.  So I thought maybe I would ask some naive questions.

But I have had the experience last year of being treated for cancer and really appreciating what a huge impact a skilled and humane nurse can have on the patient's experience.

So you've said some things that allude to the different ethical — I don't know — principles, guidelines, approaches that distinguish nursing and physician practice.  I wonder if you could highlight that a little bit more because I know as a patient there was certainly some overlap, but there were some clear differences.  So I don't know if you can articulate those more for us.

Also, I wondered about — and again, you've alluded to this — but if you were to describe central ethical issues for the nursing profession today, what might some of those be?

And then relationships with members of the medical profession and other clinicians, ethical aspects of that.

And finally, as you were speaking, I thought of an issue that has struck me just reading about it, which is the U.S. is increasing importing nurses from places like the Philippines and other countries, which probably have medical needs.  How do you see that as perhaps an ethical issue?

DR. DAY:  Wow, these are great questions.  Related to your first question about the overlap and interaction between medical practice and nursing practice, that's what I understand it to be.  I am very much unqualified to speak to medical practice.  I've been in nursing for my entire career.

I think the best doctoring, the best nursing, there is a great deal of overlap and there's a great deal of collaboration that happens.  There are different concerns, I think, in terms of meeting a patient and discovering what concerns a nurse has, what concerns a doctor has.  I think you'll find some distinctions there.

And this sort of leads into one of, I think, the biggest ethical problems nurses are faced with: this hierarchy that privileges the question of cure over basic caring practices.   Nurses are continually devalued and not taken seriously as members of the health care team.  There  are institutional impediments to this, and when we think about different practice venues like hospital based practice, there are a lot of blocks to nurses taking a full role in the team.  There are teams of physicians who round on patients and manage the medical care and treatment, and nurses change shifts every eight hours and then, you know, work three days a week and take, you know, the rest of the time off.

So it's difficult to create a cohesive team kind of practice in light of those kinds of issues.

The other thing, I think, that feeds this as an ethical problem is nurses being inadequately prepared academically to step forward and take a full role in a team of this sort.  I mean, I think that we could work out the difficulties with shift work and everything else that happens if we had some sort of momentum behind it, but I think nurses in a lot of ways are too complacent with the system as it is.

And so I think those are ethical issues because I think the patient — you know, enacting the goods of my practice, of our practice as nurses, meeting the patient and responding to the patient's needs, this can't happen in the best way that it could if we don't work as a team as health care providers.

And then could you repeat your last question, just the gist of it?

PROF. DRESSER:  I think it was the one about the U.S. bringing in nurses from other countries.

DR. DAY:  Oh, yes.  So thinking of health care internationally, there is a nursing shortage everywhere, and this importing nurses from other countries takes away from the health care infrastructure in places that have even fewer nurses than we have.  So I think it's a desperation kind of move.

The other issue with that is that the training and education that nurses receive internationally differs from that that this health care system in the United States demands.  There's an even bigger gap sometimes between the training and education nurses receive in other countries and what's demanded of them when they enter the health care system in the United States.  Different relationships with other health care providers expected; different types of communication happen here that are very culturally bound.

So I think there are lots of issues with importing nurses from other countries, and we have to begin to think about it.  I've talked with some colleagues in hospitals thinking about forming some sort of educational program or cultural development program for nurses new to the United States.  So if we could somehow enculturate them sort of quickly into this practice that has a very specific communication style, especially in hospitals, but I don't know how much success we'd have in that and then still remaining the issue of taking nurses away from places that need them as much if not more than we do.

PROF. DRESSER:  Yes, I wonder if, as you say, the shortage of nursing professors is a big part of the shortage here.  Could one argue that training more professors from here would be a more just way of handling our nursing shortage?

DR. DAY:  Yes, I think that's absolutely the root of it, and I think that putting more attention towards nursing education in many respects increasing the attention to rigor in the sciences and humanities and liberal arts education for nurses, and then making that connection with practice, and this is going to require discipline-specific teaching strategies and pedagogies.

So putting some attention towards developing the education infrastructure for nursing, and there's a faculty shortage for many reasons, and I think one of which is that there are so many options for nurses with graduate degrees.  You know, they're running clinical trials for pharmaceutical companies instead of teaching in academic settings.

And you know, the salary discrepancies and the sort of what do you get as a reward for going into academic teaching; there's very little faculty development going on in schools of nursing.  There's almost no attention paid or research going on to develop the best teaching strategies for patient outcomes.

So you know, this is a very neglected area of research.  What kind of teaching strategies will develop nurses that will then impact patient outcomes in the best way?  That's an area that's just not being attended to.

PROF. DRESSER:  Thank you.

CHAIRMAN PELLEGRINO:  I'd like to open — I'm sorry.  Any Council members desire to speak?

Dr. Carson.

DR. CARSON:  First of all, thanks for that presentation.

As a physician, I'm a big fan of nurses.  I always say they're the infantry of medicine, but a couple of things that I've noticed in medicine in recent years surrounding nursing.  First of all, there's an enormous amount of pressure now placed on nurses for documentation of everything to create the trail of virtually every case.

You know, as a surgeon, I find now in the operating room that you virtually don't even have a circulating nurse anymore because they're spending their whole time, you know, documenting everything.  And I'm not sure that this is something that's particularly useful for the patients.

And I wonder if this is something that you've noticed and that anybody is trying to address.

The other issue, of course, being one of the greatest components of good medical care is experienced nursing, and yet having nurses that stay in a particular location long enough to become experienced is becoming more and more difficult.

What do you believe are the pressures that are creating that type of situation which is very detrimental to health care?

DR. DAY:  Well, in answer to the question about documentation, it is becoming quite cumbersome, and it always has been.  There have always been discussions in nursing about how can we streamline documentation so that we don't spend all of our time writing instead of doing the care of patients.

But I think the explosion in documentation is a sign that we've lost our way in terms of professional practice because we're just trying to cover all of the bases and trying to, like you're describing, create a paper trail rather than communicate more directly with one another as providers, you know, sort of charged with the same duties and the same sort of concerns.

But I think that there are just more efforts going towards streamlining documentation, and this new thing of nurses documenting on computers is really rough on some nurses' practice, and I think it disrupts the flow, the work flow, and so getting used to that kind of new technology and new ways of doing that.

There's some discussion of having hand held computers that you can use as if it's a clipboard.  I don't know if the technology is going to allow us just to write and have it become a computerized record.  That would be really ideal because that's what nurses of my generation and older are used to, and I think maybe the new generation coming out will have more answers for us related to the documentation question.

Nurses staying in a job long enough to develop the expertise, this is one of Dr. Benner's — a seminal work in nursing practice is Dr. Benner's work applying the novice to expert model of skills acquisition to nursing and to describe nursing practice.  The development of skill from the beginner level when someone graduates from nursing school requires experiential learning over time, and so to gain expertise in the practice, to gain competence and then expertise requires one to confront similar situations repeatedly and have the sort of turning around of your assumptions in order to gain experience.

So this is a huge problem in nursing, this rapid turnover.  Nurses enter a job.  They leave after a year.  They go into a different area of practice.  They leave that place after a year, and it's a sign that nurses are not taking up their practice seriously as the self-improving practice that I described in the paper.  They're not taking seriously the importance of committing to a self-improving practice.

But I think also it's a sign that things are not going well in hospital practice, and I think that's another impediment that I didn't emphasize.  The nursing shortage itself creates an impediment because when nurses get out into practice and realize there aren't enough nurses to support me, there aren't enough colleagues for me to turn to; there's no one here who has been here more than a year.  Who am I supposed to go to with my questions?  And, you know, who am I supposed to bounce my judgments off of as a beginner?

This creates a sort of panic in the beginner because they absolutely need that in order to develop their practice.  So leaving a clinical area to jump to another clinical area, that's one thing that's happening, but another thing that's happening is leaving the practice entirely or moving out of direct patient care entirely.

And I think this is a sign that we're sort of in a crisis situation in terms of how nurses are relating to their practice and how institutions are supporting that practice.

CHAIRMAN PELLEGRINO:  Dr. McHugh.

DR. MCHUGH:  I very much enjoyed your discussion and your answers to these questions, some of which I am going to repeat a little bit in my comment to you.

And perhaps, first of all, I should tell you that I'm, like Dr. Carson, absolutely indebted to and rest upon the caregiving enterprises of the nurses at my hospital and on my unit.  We run a multi-disciplinary team that has a nurse on it, psychologist on it, occupational therapist, and it's part of the responsibility of the physician in directing that multi-disciplinary team to appreciate and to teach to others just what each of those professions will do.

And if he or she cannot do that, then the multi-disciplinary team so needed in contemporary medicine will fall apart.

But perhaps I want to come back to the idea that you presented us, that there is this problem of morale amongst nurses, and this morale derives from a number of sources that you've mentioned.  But on a multi-disciplinary team with us, at any rate, the things that become quite clear in the communications between us and our patients are, for example, the fact that only the nurse in her caring or his caring role has a sufficiently longitudinal view of the patient over the time — we're talking now in hospital — that can add to and, in fact, often correct the cross-sectional view that the doctor gets walking in saying, "Hi, how are you?" and walking out.

The person in the form of the nurse knows this and to a considerable degree the multi-disciplinary team is helped not only by the visions that they have, but by the tools that nurses can bring to quantitatively demonstrate these matters of improvement or deterioration in the patient.

And I was struck by the fact that in part what you were saying is that in the caring role that to some extent — well, I don't think you used exactly this word — but you didn't mention the importance of empirical and data driven aspects.  After all, Florence Nightingale was the first person to bring empirical work to hospital services and demonstrate how the environment and aspects really fundamentally carried by nurses made tremendous differences in morbidity and mortality.

I'm struck often by how that side of nurses' history doesn't get emphasized either in their education or in their practice.

By the way, you  make the point that the education today of nurses doesn't prepare them for practice.  I wish the education of doctors prepared them for practice.  For a great deal of our time we realize that medical school prepares us for something, but that only when we're in practice on the wards as interns, residents, and the like do we tend to realize not only what we don't know and what we need to learn, but of course where we fit into the system of interaction.

So I'm interested in what you're thinking about how the longitudinal views of nurses can be strengthened in their communications back to the team, the issue of what you're saying is that the concerns for the caring and the environment that the patients are imbedded in is very much a nursing and traditional nursing role, should be articulated.  Everyone should know about that and appreciate it.

And finally, it seems to me that the support for nurses in these enterprises should be broadly based and should involve everybody on the team in both the hierarchy of administration, as well as the doctors as well.  Otherwise you lose them.

I early learned that if I wanted to maintain a team that worked functionally, I had to be sure that I supported the enterprises of the nurses in every way, not only the enterprises of their daily work, but even the sense of their achievements, announcing them broadly to people as to what was happening.

So I'm concerned about this morale problem that seems to come forth in what you're saying, and ultimately I suppose the question I want to put to you is that if there is a multi-disciplinary team needed on a unit, whether that unit be an in-patient or an out-patient, but just take an in-patient as a model, how does authority flow in your view in this way?  Does it flow hierarchically or does it flow interactively as equals?  What is expected?  How are we sure that the things which people know get employed properly for the benefit of the patient in relationship to the issues of diagnosis, to the issues of treatment plans, issues of care delivery and the like?

DR. DAY:  Okay.  I'll try my best to follow the thread here.  I think in relation to your most recent question about the hierarchy and how does authority flow, in my vision I think it depends.  I think that it could flow different ways depending on patient need, and whichever service comes forward as the most pertinent, and that's going to require very fluid communication among team members and including patient family as participants and as members of the health care team.

I think that nurses' position, as you described, having this longitudinal access to patient changes over time, there are a couple of ways that nurses engage in hospital practice, and I'll just use hospital practice because it's what I'm most familiar with, but I'm sure it happens across different points of practice.

But nurses engage in hospital practice as the bedside staff nurse, and this is the shift worker who works eight or 12 hours on a shift, days, nights, evenings, and then there's the nurse practitioner who often works with a medical or surgical team as a member of that team, has a group of patients that she or he sees and practice is structured very much like physician practice.

So I just want to make the distinction that the nurse who has the access you're describing is the one who's the staff nurse working the shift and seeing the patient over 12 hours we hope for more than one day in a row.

So nurses developing these skills of discernment, patient changes over time, this is the thinking and action, the skilled know-how to pick up these changes, and then it can't stop there.  Nurses also need skills to articulate these changes and describe them in ways that other providers can understand.

And this is what we talk about the need in nursing education for more rigorous humanities because this is where nurses could begin to engage with these skills.  They need rhetoric, and they need to be able to describe in a way that's compelling when the situation is compelling.

So one of the issues that I think contributes to the core morale among nurses is notifying a physician team of a change in a patient's condition, getting that heard in a way that the nurse thinks it should be heard and that, you know, there are different things going on in hospitals to improve this right now because it's a big source of medical error, medical and nursing error when physicians don't hear the serious concerns of nurses related to a patient, to a change in a patient's condition.

So improving communication between nurses and physicians and educating nurses such that they take seriously their responsibility to provide the narrative, to really provide the imbedded narrative of where this patient has been and where they're likely to be going.  So that will get heard more and increase the visibility of the nurse's position as sort of the keeper of the day.  So seeing this patient over the hours that we see them.

And then your concern about the lack of attention paid to empiricism in nursing.  I think there's a push now towards evidence based nursing practice, and from the way I've described nursing practice as response based, we have to develop a relationship with the patient such that we get close enough that we know what's appropriate in this situation, and evidence based practice, research is part of it.  So the empirical studies, the control trials that tell you which intervention is the better intervention for the population, that's one piece of it, but also knowing when to choose something different based on patient preference or family concerns or this particular patient's place at this particular time.

So ultimately being responsive to patients, but, yes, I mean nurses in their education, what we found in the Carnegie study is they are very much lacking in any kind of training, in accessing empirical evidence, in doing things like searching literature, searching standards of practice, finding out what the recommendations are for standards that are based on the research evidence.  They're sort of lacking in this kind of training.

So, yes, it definitely needs to be improved, and I think by improving those skills, we'll open up nursing practice even more to be able to make these kinds of discernments.  Like is it appropriate to implement this standardized practice, or is it appropriate to deviate from that?

CHAIRMAN PELLEGRINO:  Dr. Hurlbut and then Dr. Foster.

DR. HURLBUT:  So our subject in this session is healing, and it strikes me that the whole notion of healing is a conceptual framing of reality.  It starts with certain assumptions about the nature of human life, of our meaning and purpose in life, and our whole relationship with natural process.

Early in my medical training it struck me that as I got into the clinical wards, I noticed that nurses were doing a lot of what I had seen medicine as being about in a way that even the physicians weren't in the sense that they were encountering the patient at the most sensitive and vulnerable moments and delivering a kind of compassionate care and a very human element of healing that transcended in some sense even the technical dimensions of healing that physicians were more assigned to.

So it struck me even then that this is a very difficult encounter.  It's an encounter with disorder, disease and death itself, and in fact, was an emphasis of life that's very different to the prevailing preoccupations of our entertainment oriented, consumer culture; that whereas the emphasis in — and I understand it — in much of our lives is toward the bright and the happy and the easy and the exciting, this was an encounter with something of difficulty and depth, a kind of intensity.

And I began to realize that this was very draining on the people who were closest to it, and it struck me that the nurses were actually closer to it even than many of the physicians.

So what I want to ask you is if you'd comment broadly a little on that.  It strikes me that you say that nurses move quickly out of their roles, I guess moving on to different jobs, a kind of restless dissatisfaction.   I would imagine nurses also leave practice probably more than people expect.

And would you comment a little on the whole prevailing question of cultural values and the difficulty of being a nurse and encountering something that we barely have a culture to contain anymore?

What I'm thinking of here, not to put words in your mouth, but to ask you seriously about:  is there an emphasis in our culture that does not face fundamental realities?  And is there an emphasis that doesn't set the proper frame for medicine in its deepest and most difficult role, that being the compassionate engagement with those in need of healing?

And just one little point I want to add on this.  It strikes me as rather fascinating that even as our culture does not emphasize those qualities of personal vocation, it is interesting that even in our entertainment oriented world there is a new and growing emphasis — it's been around a few decades — but a growing emphasis on entertainment through medical drama; that there is a strange intensity and authenticity to this encounter that actually is missing in much of our daily life.

So I guess what I'm asking is could you just comment broadly on this and perhaps give us some reflections on how we might integrate these deeply meaningful realities in a broader sense culturally, whether that might reinforce and encourage the important role of nursing.

And if you have a statistic on how long nurses actually practice once trained, I'd be interested to hear that.

DR. DAY:  I'm afraid I don't have the statistic, and it varies institutionally.  The most concern about this comes up in hospitals where they see a rapid turnover.  They put a lot of effort into new graduate orientation and training, and then they see a turnover.  So there are lots of efforts being made now in hospitals to retain new nurses.

In terms of the cultural turning away from what nurses sort of steep ourselves in, this is something that student nurses encounter when they take up the practice and they realize that what they talk about isn't what most people want to hear about.  So they form very strong bonds with one another because other nurses are who you can talk about this with and probably physicians also and others in health care practice in this sort of intense way.

But yeah, it's interesting.  I had a student once who told me that she used to watch the TV program "ER" religiously.  She loved this program "ER" until she started nursing school and began to actually immerse herself in the realities of this.  Then "ER" no longer sustained her.

So engaging in this reality and the real sort of suffering and vulnerability, I think it's confronting your own vulnerability, and this is, you know, what I described as we share with those we seek to help.  So it's a frightening thing, and to find ways to cope with that and to support one another around it, I think I don't know.  I don't have an answer about how we could begin to spread this or permeate this seriousness into the rest of society.

I think it would be a really good thing for many reasons and also to think about health in a much bigger sense than just the absence of disease.  That social well-being and connection to the natural environment in ways such as good nutrition and farming practices.  These kinds of things, it seems as though there may be something happening at a sort of more grassroots level, but I don't know how we can change the cultural penchant to entertainment, and I think the fascination with medical practice and surgical practice, you know, these reality TV shows that show you the plastic surgery or whatever that are happening now, I think that there's a fascination with the power of the biomedical model and the curative model, and there's less interest in things like caring for people over time who are living with chronic disease and illness.

That's much less interesting to people.  So I think this kind of rescue mentality, and this feeds the way our health care system is structured.  I don't know which came first, but we've got a definite over balance of cure, and much neglect of helping people cope with the day-to-day life with chronic illness, and this is where I think the shift needs to happen in health care and also less attention to public health.   Environmental health concerns are being neglected.

So shoring up the infrastructure, shifting the balance, shifting the emphasis away from dramatic cure because that's less and less feasible with the kinds of health issues we confront.

CHAIRMAN PELLEGRINO:  Dr. Foster.

DR. FOSTER:  I want to say to the visitors here that Council members tend to ask lots of question.  I was counting all of the questions that come to you from each speaker, and I couldn't even keep up with them myself.  So I'm only going to make a comment and not ask you any questions at all.

You've talked a lot about education, and it's a problem.  You say, "Well, we've got to learn about ethics and humanities and then the technical things," and I'm sure the Carnegie group and everybody else is going to have to come to the grips that all of us have to come to grips with, is that we have to prioritize what we can do in a limited time of education, whether it's four years of medical school of nursing or college.  You just can't do everything.

I addressed the new interns at Southwestern this week, and I pointed out that in 2004 — I think I mentioned this in the Council once before — there were 550,000 papers published in the 4,000 journals at the National Library of Medicine Archives.  That's a paper a minute.

Now, let's say that one out of 1,000 are important.  That's still a huge number of papers that you have to do.  So you have to make a prioritization, and one of the things I told them — Bud Relman will faint on this — that rarely read a whole paper.  You don't have enough time.  Read the introduction and the thing.  I tell them to read your journal.  That will keep up with everything that's going on.

But we have to prioritize about what we can do.  We can't become an expert in ethics or an expert in nursing, and I think that's one of the critical problems to do.  It's just too much information.

The second thing I want to say is that my observation is that people are happy in what they do if they get a sense that they're doing something important.  You know, Kierkegaard developed the concept of like for like.  What you give you get, and Emerson once said in a graduation address that there is a justice that is instant and inevitable; that if we do a noble thing, we're ennobled, and if we do a mean thing, we contract.

There has to be a sense that what one is doing is humanly important.  I mean, in nursing it's humanly important.  They have to get that sense, and that way the assets to the job markedly override the liabilities.  I've got to keep documentation of everything.  If you get a sense that what I've done is actually to help somebody go through what Bill Hurlbut knows they've talked about their difficulty.  We've got to better show that by the teachers and so forth that they can do that.  So they get a sense.

I use a little homely thing.  There's a floor cleaner in Parkland Hospital, which is where I work, which is a big charity hospital, and he cleans and polishes the floors on the wards, and if you look at his polisher, the chrome on it is shining, and he cleans the floors and I've gotten to know him.  He and his wife have put two kids through college and so forth working two jobs.  He said to me one time — I stopped and I said, "Mr. So-and-so, I'm really impressed at how you keep these floors polished."

And he said, "Well, the hospital is not going to work if it's not clean."  He polished the floor, but he thought that he was part of the curing and healing and comforting business.  He had a sense of what this was about.

And if we don't get that, salary won't make up for that.  That has to be, too.  So I just want to say I think that with nursing leaders like yourself, just like the academicians in medicine are going to have to prioritize what they can teach in a fixed period of time.

And secondly, we have to have this sense of being important.  What I say to the interns is there are only two things important in your life.  One is to be competent.  If you're not competent, you may have the greatest heart in the world, but you're unethical if you're not competent.

And secondly, you have to comfort.  Those are the two Cs is what we need.  Okay.  So I just think this is not an easy thing, but they've got to feel, we have to feel that this is really important, humanely important as well as technically important.

DR. DAY:  I completely agree, and I think that when we think about prioritizing what can we teach, I think too often we go to content, and this is what we've seen in nurse educators in the classrooms with nursing students.  The content overload, just how many facts does one person need to memorize before they can go into the hospital and meet a patient?

I think we focus too much on the number of facts, and we have to add things about genetics now and we have to add things about, you know, just different facts and different content areas.

But I think that we can't pass over the formation of the developing nurse, and that's instilling them with the sense of importance, the sense of the seriousness of the task at hand, and this kind of engagement and access to the practice doesn't seem to be happening in the education.  We need to develop educators who can open this up for students better because students find that they don't learn anything in the classroom.  They learn it all in the clinical arena, and in the clinical arena, they have hit and miss role models.  Some nurses are pretty disenchanted with the practice, and they're not good people to introduce new nurses to the seriousness and the importance of the work that we're doing.

So making sure that students get a sense of the importance of the work that we're doing and carry that forward, I think that is the essential aspect.

Competence and a knowledge base, having some skilled know-how and ability to develop clinical judgment in practice is essential, and having a knowledge base that allows you to do that is essential, but when we focus too much on what content should I include or not include in my lecture, I think that's where we get into trouble.  We need to be thinking about the formation and the access to the practice that we're affording with all of our teaching.

CHAIRMAN PELLEGRINO:  Dr. Meilaender.

DR. FOSTER:  If I can respond in one quick way to say that the constant error in all teaching didactic is putting in too much and not having too little.  I mean you see that in every grand rounds, and so forth, every biochemical lecture.  The error is most often too much rather than not enough.

PROF. MEILAENDER:I thought we needed someone other than a doctor to say something to you.

I've been sitting here kind of trying to figure out what we have to contribute, what the Council on Bioethics has to contribute, and it's not your job, of course, to tell us that, but I'm still not clear entirely, but I'd like to just press a little bit.  This in a way follows up on Dan Foster's comment, but maybe pushes it a little harder.

Because I don't think the issue at least as I listen to you, I don't think that the issue is simply the sheer mass of information, which I acknowledge and which is obviously going to create problems, but it seems to me as if you've got a couple different things going, and I'm not sure they're compatible.

On the one hand, you want better attention to formation, to nurses who are able to enact the goods internal to the practice of nursing and so forth, and I mean, one learns to enact the goods internal to a practice by practicing.  It's not simply a theoretical undertaking.  It's an experiential one.

And on the other hand, there's a need for more scientific knowledge and so forth driven, it sounded to me — now you may wish to correct me — but driven it sounded to me by the sense that this is needed if we're to redress the imbalance in the professional hierarchy that pervades medicine.

But, I mean, maybe the practice of nursing needs to think about kind of what kind of practice it primarily is and maybe it doesn't need to worry so much about redressing the hierarchical imbalance.  I mean, I'm sure that I understand that creates problems sometimes.  All of the doctors who spoke are very careful to appreciate nurses and so forth, but I mean, these are a couple of different kinds of learning, and you even want to toss in you want these nurses to be well trained in the liberal arts as well.  You know, they should read Plato, too.

I think, you know, there be just a kind of incoherence of desire here in what you're looking for.  These are different kinds of learning.  They're not separate entirely, but they're still different kinds, and maybe the practice of nursing needs to think about what sort of learning it primarily is.

Now, I may have put that too strongly, and yet it just seems to me that there is the kind of tension in your wanting everything, and the problem is not just that it's too many things.  That's partly the problem, but that it's the different things, and one needs to think about kind of what primarily you're up to, if that makes sense.

DR. DAY:  Yeah, it does, and it helps points out a way in which I think I haven't been clear.  I think there are different ways of thinking that nurses need to engage with, and so when I think about nurses reading Plato, I don't think about them engaging in the same way that a philosopher would engage with reading Plato, but I think about them gaining something valuable for their practice in reading this dialogical method.

And a nurse — this is why I say the liberal arts specifically geared towards the undertaking of the practice of nursing so that if I were to assign a reading from Plato in my class, I would specifically have some specific ideas about how that would lend itself to the practice of nursing, what kinds of skills and knowledge nurses would gain that would be valuable to them as nurses.

And I think there are all sorts of things like this that nursing education neglects, and in terms of the breadth of knowledge needed for the practice, I think there is a huge breadth of knowledge needed for the practice, and I think engaging with what nurses need to know, it depends on what area they decide to practice in, and that's another big issue in nursing education is how much specialization should go on early on, but in terms of just a general practice of nursing, to think about that nurses may not need the same kind of science that a bench scientist needs, you know, a biochemist who's working at bench science, nurses don't need the same kind of understanding of chemistry as that person needs.

But there has been this sort of tendency in nursing education to what's called dumb down the science and not give nurses the kind of rigorous training that we need in sort of thinking about science in the way that we need to think about it.  So it's not that I'm saying that we need to train as if we're going to go into a life of biochemistry, but we do need to have a grasp of what's happening in this sort of current model for understanding disease.  Nurses need a fluent grasp of that.

And in what I've seen in nursing education, they are not necessarily getting that.  So it is a way, and I see it as a way to address the hierarchy, the problem with hierarchy of medicine and nursing being in the sort of very unequal status in hospital practice, but I don't see that as the ultimate point of giving nurses this more rigorous education.

I see the point of giving nurses the rigorous education to better prepare them to address the patient care issues that they're confronting and also to confront the system that they're working within.

A nurse that we interviewed who had come back to school, she had graduated from a community college with an Associate degree and then gone back to school for a Bachelor's completion program.  She described the world that opened up for her, the possibilities it opened up when she learned how to write grammatically correct sentences.  And she could finally write the letter to her supervisor to explain exactly why it was a problem not to have the adequate staffing in the area she was working in.

So these kinds of basic skills are being neglected in nursing, and to address this sort of when I say humanities, things like English, basic writing, being able to make an argument, being able to convey, to evoke a situation for someone else to understand it.  I think nurses are in many ways not able to do that adequately.

So this is the kind of education that I'm calling for, is not to take nurses down the path of, you know, studying philosophy and being able to write a dissertation on Plato, but taking up Plato.  Look at the dialogues.  Look at what is happening in this dialogue and how the argument is being built, and how could you use that in your practice?

PROF. MEILAENDER:That's all.  I don't quarrel with any of that.  I just, as somebody who has spent his life teaching undergraduates,  one, I just want to say that's not really liberal arts education.  That's a certain kind of training in the service of professional competence, and that's fine.  I have no quarrel with it.  It's just not really liberal arts education.

DR. DAY:  Yeah, and there really are two things, and this is a discussion that we've had within the Carnegie team as well.   There really are two things that we're calling for.  One is the liberal arts as a way of opening up thinking that's not related to the practice.  So not taking up reading Plato for Plato, and I think there's a lot of that for nurses.

And then, you know, when nurses get into practice, realizing you know, what I read in that philosophy class really has opened up some different possibilities for me here, but reading it with a philosophy professor who's not concerned with the practice of nursing but is giving future nurses, those who maybe haven't even decided on nursing school yet, but giving them some foundation in different ways of thinking, different ways of approaching others.

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Day.  More, I want to thank you for responding so promptly and also for your stimulating discussion.

We have a schedule.  Dr. Kass, go ahead.

DR. KASS:  Thank you.  Much of what you say about sort of the institutional emphasis on cures, the neglect of chronic illness, public health, environmental health, nutrition, and so on, would be part of a speech made by someone who wants also to reform the medical profession and the way medicine is practiced and how we think about the new problems of medicine now, some but by no means all of the efforts of curative medicine that have succeeded.

But the one difference would be that the doctors would not complain about the hierarchy question, and my good friend General Carson spoke of the nurses as the infantry.  This is a complaint that one has heard for years.  It's in a way partly built into the system, and these are complicated matters, but I wonder whether one doesn't sort of have to acknowledge that while every member of this team has not only special skills but possibly special insights into what's needed for the well-being of the patient, someone has to be primarily responsible, and it has to somehow, I think, be understood, unless you want to disagree with this, that both as a matter of law, as a matter of responsibility, as a matter of competence that this has to be a team which is led by physicians.

Now, it might be there are certain areas in which one really says, "Look.  Nurses do this vastly better.  It should be their area."  But I wonder whether the emphasis on the hierarchy question is the right one.  If everyone, as Dan said, thought their work was somehow valued and appreciated, the resentment of where one is in the overall chain of responsibility might disappear unless this was a question of envy and resentment for the inequality as such.

So I really wonder what you'd say about that.

DR. DAY:  Well, I think it's interesting because I do agree that there has to be some sort of accountability.  I mean, there has to be a person who's accountable ultimately.  The issues of hierarchy that I'm thinking of are the ones that don't make sense, and so some attention to at what point does it make sense for this person to take the lead and at what point does it make sense for this other person to take the lead.

And I think the assumption is made that the physician always takes the lead, and I've run into this in things like, for example, family conferences.  There came a question in the hospital where I was practicing that when we have family conferences the physician always takes the lead when at times the nurse is the one who has been more closely communicating with the family on an hour-to-hour, day-to-day basis, and why is it that the physician always takes the lead in these settings?

And so those kinds of hierarchy concerns that I have are not really about who's ultimately accountable or who's sort of running this treatment while the patient is hospitalized, making decisions about what treatments will go forward, but it's more this kind of day-to-day like how are we communicating.  Who's listening to whom?  And who's being devalued and discounted and ignored?

And I think that nursing concerns are often ignored.  One of the things that I point out to my students is that they have an experience in an intensive care unit where they always are so impressed by the collaboration between physicians and nurses in intensive care units, and that has to do with a lot of different things, but I think one of the things it might have to do with is the very clear concern that everyone has for physiologic stability in the intensive care.

I mean, patients are very on the edge in that environment.  So medical and nursing concerns very much line up, and we're all looking towards the same thing.  We need to titrate vasopressors.  We need to wean this person off the ventilator or make changes, all geared towards physiologic stability.

The patient moves out of that intense environment to an acute care unit where the vulnerability for physiology is not so desperate.  Nursing and medicine concerns diverge much more, and now what happens is nursing gets ignored, and there is no longer any collaboration among the team members.

So that's sort of what I'm thinking of as hierarchy, not so much who's making decisions but who's listening and what kind of input are decision makers getting, and does it make sense for this person to be the decision maker in this situation or would it make more sense for someone else to be?

CHAIRMAN PELLEGRINO:  Thank you very much. 

I'm sorry for the quick foot on the accelerator.  I didn't see Dr. Kass' hand.

Thank you, again, and I'm going to take the Chairman's prerogative of going on with the agenda in a modified way because what's coming this afternoon.  We're trying to get everything in.  So I'm not going to have a coffee break.  For those of you who need the stimulus of a little coffee and other related agents, feel free to go out and get a cup and come back, but I'd like to move on to the next speaker so that we can accommodate Dr. Sullivan when he comes in and move into the panel and give everyone a chance we promised them to speak.

So I will now ask Dr. Relman to address us.  Again, I point out that the credentials and background of all the speakers is in the agenda and the agenda book.

It is often said that some people do not need to be introduced.  It doesn't always apply, but it surely is the case here with Dr. Relman.  He was an emeritus professor at Harvard of medicine and also is the former editor of the New England Journal of Medicine.

Bud, thank you very much for joining us.

DR. RELMAN:  Thank you very much.

It's an honor and a privilege to be here and to talk about medical professionalism, a subject that is much discussed, but yet I believe, as I will point out, much neglected.

I believe that medical professionalism in this country is facing a crisis just as serious as the crisis facing our health care system itself, and that's profound, and I believe the two crises are interrelated.  In this presentation I want first to explain what I mean by "medical professionalism," why it is being threatened, and what is at stake.

After that,  I will briefly suggest what I think needs to be done and what I think this Council might contribute by dealing with the problem.

Now, to understand the crisis of medical professionalism we need to remind ourselves of what a profession is and what role it plays in modern society.  There's a huge literature on the subject, but in my opinion the late Eliot Freidson, the distinguished sociologist at NYU, wrote one of the most insightful analyses of the professions.

He considered a profession to be one of what he called three options modern society has for controlling and organizing work.  The other two options aside from a profession are, one, the free market and, two, management by organizations, such as government or private business.  He believed that medical work was totally unsuited for control by the market or by business or government.  So in his view the practice of medicine could only be conducted properly as a profession.  It had to be a profession.

Well, what does it mean to be a profession?  According to Freidson, a profession has certain distinguishing characteristics.  Its work is highly specialized and grounded in a body of knowledge and skills that is given special status in the labor force.  Its members are certified through a formal educational program that is controlled by the profession itself, and qualified members of a profession are granted exclusive jurisdiction and a sheltered position in the labor market.

Finally, and most important of all according to Freidson, professionals have a ideology that assigns a higher priority to doing useful and needed work than to economic rewards, an ideology that focuses more on the quality than the economic efficiency of the work.

In my view, this ideology is the essence of medical professionalism.  More than almost any other profession, the practice of medicine is based on an ethical commitment to those it serves, i.e., its patients, and to society.  The threatened loss of this commitment is what concerns me here.  That's the crisis.

And I use my words carefully.  I believe it is a crisis.  What is endangered, it seems to me, well, let me say that the science and technology of medicine and the special place that medical practice holds in the labor market are not at risk.  What is endangered are the ethical foundations of medicine, and by that I mean the commitment of physicians to put the needs of their patients ahead of their own personal gain, to deal with their patients honestly, competently, and compassionately, and to avoid conflicts of interest that could undermine the public trust in the altruism of medicine.

It is this commitment, what Freidson is pleased to call the soul of the profession, that is eroding before our eyes, even while its scientific and technical base grows stronger.  It's ironical, but medical science and technology are flourishing as never before while the moral foundations of the medical profession lose their influence on the behavior of physicians.

This undermining of the ethical underpinnings of medical practice is an integral part of the sea change in the scientific, economic, legal, and social environment in which medicine is now being practiced.  The coincidence of all these events is a story too large for full exposition here.  I've told it and documented it as well as I could in a little book that I've just published called A Second Opinion.  So I'm going to mention only a few points here.

In the book, I argue that one major reason for the decline of medical professional values is that medical care in the United States has become so commercialized.  I noted with interest that Dr. Day, who preceded me with her excellent talk about the nursing profession, identified profits and the economic behavior of the health care system as one of the impediments to the nursing professionalism.

The health care system in the United States can be described not inaccurately and not in any sense of exaggeration as an over $2 trillion industry largely shaped by the arrival and growth of innumerable private, investor-owned businesses that sell health insurance and deliver both in-patient and out-patient medical care.

To survive in this new medical market, most nonprofit medical institutions, and they constitute — it's very hard to get accurate, quantitative numbers, but my best estimate is that the nonprofit institutions still slightly outnumber the for-profit medical institutions in the country, but not by much, by less and less.

But the point is that to survive in this new medical market most nonprofit medical institutions must act just like their for-profit competitors.  So the behavior of nonprofits and for-profits has become less and less distinguishable.

There are notable exceptions, and I tip my hat to them.  There are very notable exceptions, but by and large, the not-for-profit health care institutions in this country are more and more being driven by the same bottom line considerations as the for-profits, and in no other health care system in the world do investors and business considerations play such an important role.  In no other country are the organizations that provide medical care so driven by income and profit generating considerations.

This uniquely American development is an important cause of the health cost crisis, the health cost crisis, that is destabilizing our entire economy, and it has played a major part in eroding the ethical, professional commitment of our physicians.  That's what my book is about.

Physicians for their part have contributed to this transformation by accepting the view that medical practice, like the organizations that provide the venue and the resources for the delivery of care, is also, in essence, a business.  In this view, it is a very technical business, to be sure, one that certainly requires adequate credentialed education and great personal responsibilities, but a business nevertheless.

Business people consider profit and income as a primary end, but medical professionalism should require giving even greater primacy to the needs of patients.  It is not that physicians haven't always been concerned with earning their living.  I'm sometimes accused of being unrealistic and not recognizing that even in the good old days when I started out in medicine physicians were always worried about earning their living, and in a certain sense behaved like businessmen.

Of course they were.  They had to be.  Those are the realities.  And there were always some physicians, even in the good old days, who were far too driven by greed and acted unethically because of that.

But the current focus on money making and the seductions of monetary reward have changed the climate in U.S. medical practice at the expense of professional altruism and the moral commitment to one's patients.  The vast amount of money in play in our medical care system and the manifold opportunities for physicians to make money has made it difficult, almost impossible for far too many physicians to function as moral agents, as true fiduciaries for their patients.

Now, I think that's unassailable, and I would be willing to defend that proposition against all comers with innumerable examples of the fact that medicine has become far too commercialized, and that's a sea change.  It didn't exist 30 or 40 years ago or 50 years ago when I was a young physician.

Let me be clear though that I do not consider business to be inherently immoral or even amoral, although some would challenge that.  I certainly don't consider it inherently immoral.  I am no beef against business, and I'm not arguing for a socialistic ethic.  God forbid.

I am simply saying that the essence of the practice of medicine is so different from that of ordinary business that the two are inherently at odds.  Yes, business concepts of efficiency and effective management may be useful in medical practice, but only to a certain point.  The fundamental ethos of medical practice is different from that of ordinary commerce and market principles cannot adequately describe the relation between physician and patient.

In 1963, economist Kenneth Arrow, later shared a Nobel Prize, was among the first to recognize that fact.  But those insights didn't stop the advance of the medical-industrial complex, as I termed it in those days, and the triumph of market ideology over professional values in the practice of medicine that now characterizes the U.S. health care system.

Other forces in the new environment have also been eroding medical professionalism.  The growth of technology and of specialization, a great blessing, may increase the power, the curative and the preventive and the healing power of medicine, enormously.  The growth of technology and of specialization is attracting more and more physicians into specialties and away from primary care, thus further weakening the personal bond between doctor and patient.  The episodic involvement of the specialist with the physician is different from the ongoing personal caring, long term commitment of the classical view of the physician as healer.

The vastly greater economic rewards of procedural specialties are particularly appealing to new graduates who enter practice burdened with very large educational debts.  Specialization is not incompatible with ethical professional practice, but it often reduces the opportunities for physicians and patients to interact in ways that kindle the relations upon which moral behavior depends.

It is all too easy for even the best of specialists to act simply as highly skilled technicians, to do their thing as competently as they can and then move on.

The law, too, has played a major role in the decline of medical professionalism, and the more I think about it the more outraged I get at this fact.  When the Supreme Court in 1975 ruled that the professions were not protected from the thrust of anti-trust law, it undermined the traditional restraint that medical professional societies had always placed on the more crassly commercial behavior of physicians.  Having lost some key legal battles after that, after the Supreme Court decision, organized medicine now fears, is terrified to require that physicians behave differently from business people.  It asks only that physicians' business activities should be legal, disclose to patients, and not inconsistent with the patient's interest, a far cry from the earlier moral strictures placed upon the doctor-patient relationship.

Until forced by anti-trust fears to change its ethical code in 1980, the American Medical Association had always held that — and now I quote from the ethical guidelines of the '50s, '60s and '70s — "in the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him or under his supervision to his patients."

It also had said that "the practice of medicine should not be commercialized nor treated as a commodity in trade."

These fine sentiments reflected the spirit of professionalism that motivated medicine when I was a young physician, but they are now gone, along with the unthinking universal description of the physician as a man.

Very shortly, to the enormous benefit of medicine, very shortly about half of all practicing physicians will be women.

Yet another de-professionalizing force has been the growing influence of the pharmaceutical industry on the practice of medicine.  This industry now uses its enormous financial resources to shape the postgraduate and continuing medical education of physicians in ways that serve its marketing purposes.  Physicians and medical institutions for their part aid and abet this influence by accepting, sometimes even soliciting financial help and other favors from the industry, thus relinquishing what should be their own professional responsibility for self-education.

A medical profession that is being educated in the practice of medicine, at least in the practice of pharmacological medicine, by an industry that sells the drugs and other tools that physicians prescribe is abdicating its ethical commitment to serve as the independent fiduciary for its patients.

I should say that there's been a recent backlash against this, but it's just starting and a few courageous institutions, students and faculty and administrators are saying, "Stop.  We're not going to allow the pharmaceutical industry to take over our educational responsibilities in pharmacotherapy, and we're going to draw some barriers.  We're going to set some walls between the sales representatives of the industry and our academic institutions."

More power to them, but they've got an uphill struggle against enormous financial resources that are being involved here.

Well, given all of these anti-professional forces and given the historical change I have described, why not accept what appears to be the judgment of history?  Why is the preservation of professional commitment in medicine still so important?

I believe the answer is because physicians are at the center of our health care system and the public must be able to depend on and trust the altruistic motives of its physicians.

Now, it is currently fashionable to be concerned about the paternalism and elitism of medicine, and certainly there's plenty of that.  I do not defend the paternalism and the elitism of medicine.  I've argued against that for a long time.  And it's certainly fashionable now to champion the notion of so-called consumer directed health care, and I'm all for educating and empowering consumers as much as possible, as much as practical.

But while there is undoubtedly a need for more information and responsibility to be given to patients, the fact remains that without trustworthy and accountable medical professional guidance, our health care system can't work.  A medical profession not motivated by a strong ethical commitment to patients simply cannot fill that role.  Without such commitment, health care becomes simply another industry, and we continue along the present course that is increasing the influence of market forces and the role of business corporations and government.

I didn't emphasize, but Freidson is quite right.  If the medical profession itself is not going to assume the responsibility for monitoring and directing the professional behavior of its members, then either business and/or government is going to step in for sure.  This trend is inevitably heading toward the bankruptcy and collapse of our health care system, along with the de-professionalization of medical practice.

I argue in my book that we simply can't afford to accept the industrialization of our medical care and that we must work toward major reforms that restore our health care system to its proper social rule.  In essence, my argument is that industry naturally and understandably working for its investors' primary interest constantly wants to increase its income, and those are the costs that are breaking the bank.

So, in essence, what you have now is a contest between the 16 or 16 and a half percent of the American economy that's tied up in health care, much of which now is being driven by income seeking and the interests of investors, and the other 84 percent of the American economy which has to pay the cost.  And that's what the CEO of General Motors is now complaining.  It's breaking the bank.  It can't continue.  We have to control health care costs, and we have to make health care more efficient, more effective, serve the public interest.

So I argue that an essential part of the necessary  reforms must be a rededication of physicians to the ethical professional principles upon which the practice of medicine should rest.  The reforms I envision require not only public and political initiatives, but also the active participation of the medical profession.  In my book, I have a chapter entitled "An Open Letter to my Colleagues in the Medical Profession," and I say this is your last chance.  You either will be part of the solution to make the health care system in the future serve the public interest and preserve professionalism or else you're going to be part of the problem and you're going to be swept aside by the inevitable advance of government and private corporations into the health care system.

Now, what could this Council do to help defend and rekindle the ethical foundations of medical practice and thereby promote the integrity and vitality of medicine as a profession? 

I believe that you have major opportunities for constructive engagement in this effort.  You are an influential body and you stand outside of organized medicine and apart from the practicing physician.  You cannot be accused of protecting the welfare of physicians or arguing for any other special interests.  Your judgment on the issues I have discussed here will carry weight not only with the public, but with the profession.

We physicians, it's a habit of thought that we're taught to adopt; we physicians usually pay careful attention to outside experts whenever those experts talk about matters beyond our experience.  We treat the specialist who knows something that we don't know with great reverence.

You are specialists in ethical and social, cultural behavior.  You can say something very important and influential about what role medicine as a profession should play in American society.  Physicians will respect your qualifications as bioethicists and they will listen.

If you were to decide that medicine has become too commercialized, that commercialism undermines the ethical commitments of physicians, and that this erosion of professionalism is not in the public interest, then it seems to me that you should speak out, particularly at this juncture.  In the rapidly expanding crisis in health care, I believe your opinions would receive wide attention and make an invaluable contribution.

Thank you for your attention.  I'd be happy to take your questions.

(Applause.)

CHAIRMAN PELLEGRINO:  Bud, would you sit down and answer the questions?

DR. RELMAN:  Sure.

CHAIRMAN PELLEGRINO:  We've asked Dr. Paul McHugh to open the discussion.

DR. MCHUGH:  Well, Dr. Relman, that was a splendid, certain trumpet, and I was impressed by your last statement that we, if we have such influence, could alter and shape the future of our country in interesting and important ways that you and I and, I think, all the doctors here absolutely agree about about the importance of professionalism.

But there's something about this Council you have to understand.  Part of the issue of this Council is that we bring people to us because we're ignorant about the matters, and then talk about them amongst ourselves in relationship to developing attitudes and developing things that go beyond our professional commitment.

If you and I were just sitting down together and the other doctors here were at a doctoring convention, we'd all just stand up with you and run to the barricades and blast away and wouldn't have to think anything more about it.  You'd just win us around and we win.

But on the other hand, we're here in a bioethics council of people that are intended to spur public discussion over matters that are considering things from several other points of view than just the doctor's point of view.  And I think that's the issue that I was trembling, trembling before your marvelous passion on which I agree.

I want to raise some issues and wonder about in relationship not to professionalism.  Certainly I agree with that, but in relationship to health systems and things of that sort that come out.

Now, I haven't read your book, but I have read these little articles that were sent with us and I've seen and read editorials of yours before, which I've always loved and admired, and I came to it today.  Since just a couple of days ago I was spotted as the person that should speak up.  I thought about what I might say, and to begin with, the most wonderful thing about your writing is the way you go at this issue of profit and show that the promotion of medication use is an expensive service by for-profit activities and institutions; has generated wants for patient services that may not be needed by patients.  That's one way you do it.

And then you go around and turn it right around the other way marvelously and say the restriction of services by profit managed care companies now employed by health insurance, their profit driven things, may by depriving patients of what they want, may also deprive them of what they need.

DR. RELMAN:  Sounds like a great system, doesn't it?

DR. MCHUGH:  I mean, I thought that was a fantastically delightful way of attacking the profit issues and the like.

And now though I'm going to move off in another way to talk a little bit about what somebody who's not perhaps a doctor might wonder about what's happening, and by the way, you talk about the good old days.  I was there in the good old days, you know.  Those good old days were rescued by the health insurance company.  You and I were paid about twenty-five —

DR. RELMAN:  "Good" was in quotes.

DR. MCHUGH:  Yeah, that's right.

You and I were paid, I was paid $25 a month for the happy opportunity to be a house officer at the Peter Bent Brigham Hospital every other night and every other weekend, and I have to tell you I was happy as a clam at high water at the time, but money and things of that sort were neglected for many of my colleagues, some of whom, by the way, with families were on welfare at the very time they were members of the house staff at the Peter Bent Brigham.

And with the advance of technology, of course, great money flowed into our hospitals rescuing them in the face of the costs of technology and in the process, some of that money has flowed to now that people graduate from medical school and go into internships and have, well, quite nice salaries.  And I don't want to deny them that. Okay?

But when it comes to the health system and how we could come at this bioethically, you have to take another view of what government can do and what we should be doing with a system and want to be sure that how you look at people will determine a little bit about what health care services have provided, preferably by professions.

If you think of people as either all kind of vulnerable or misguided children or simply parts of a community machine that's running for the greatest good of the greatest numbers, and they need service, you'll emphasize a certain health system where experts must determine the needs of people and the health services supply those needs doing the fix for the cogs under expert direction, matters such as how the needs will be met, what the people will have to do to get them, how the social goods meeting these needs will be equitably distributed, and even when experts might think that meeting certain needs becomes futile and useless and should be withdrawn from certain people.  Let these experts do it.

Such an enterprise would, like all needs, be really part of the fabric of society, the tax supported things like police, fire and education.

If you think of the citizenry of America as being full of people with needs, you're going to have one kind of approach.  If, on the other hand, you think of the people as individuals who can and should run their own lives and then decide for themselves how to choose to use their resources in terms of both the prices paid for services and the opportunity costs appreciated by their choices, then you might think to build a system in which what they want can be purchased and their foresight stimulated by teaching them to become better consumers on health matters, making savings and insurance plans accessible to them at reasonable rates, and providing the services to them in attractive packages.  The Brigham no longer has E-main where we used to distribute ourselves in little beds around a huge ward, but in lovely accommodations.

The real problem, of course, is that neither of these pictures of human life is complete.  Some people are helpless, powerless in the face of illness and disease, and destitute, and some situations are so catastrophic, destroying a breadwinner and demanding child care, that the best laid plans of anybody are overwhelmed, and here needs trump everything and a system must be provided and we must support it to save lives and to save households.

The suggestion though that what is appropriate in a system that is need-driven and so guarantees our response to catastrophe should be the general system rather than a component, an emergency backup of a want system, might be not the best.  Not only does such need drive things, perhaps encourage dependency in the whole public, they also tend to grow without limit as the British discovered because the demands for needs, you know, they have no restraint.  They certainly tend to provoke inconveniences and often deprivations and can become tyrannous, as I said, in relationship to what kinds of needs are going to be supplied as experts tell us who and what we must do and what we must put up with.

The opportunity costs from those other systems, that system, burgeoning expenses as more and more techniques are drawn in, are carried by a society rather than by individuals, a society that may lose ability to make other investments and respond to other threats and build other supports for family life, safety and the like.

Thinking this way, for example, I can't see the United States perhaps deciding like Britain with its initial national health service, they have governed both the insurance of health care by paying for it as well as the organizer of health care by organizing the hospitals and owning the hospitals.  We'll probably opt for a two-tier system, and I think it's the two-tier system that is problematic.  I think it's what you know, in which the government will be prepared to be the insurer of need, as in Medicare and Medicaid that did save the hospitals, but private insurance, the management of private insurance, will be negotiated by individuals so that we can have what we want and pay for it as adults with a plan for life that we'll prepare.

Rewards, just to come finally back to the profit thing, rewards will continue to be provided in this system.  I mean, we're rewarding our interns much better than I was rewarded financially.

By the way, they're not much more happy; they're not as happy as I was in those old days, but rewards will be.

Services will improve with better expertise and we'll meet the wants and ultimately share them with others.  So that's what an amateur look at economics, politics, and services thinks, and it derives from watching this system in America that you think has come to a crisis, slowly evolve in a trial and error fashion.  That's what we did, trial and error.  We didn't have a revolution in health care like they did in Britain.  I'm not sure that's not the best way.

So here's my questions to you after all of that preamble.  Do you see your views as supporting and derived from an evolutionary process with the conception of what government can do, what private things can do and cannot do and should not do, rather than a big revolution?  Are we going to have to have a huge revolution here in health care in order to once again restore professionalism?

Do you have some actual plans, government plans, noting them in their particular local successes and failures?  For example, you know, are they doing this better in Canada?  Did the internal markets in the British health system make for a better service there as they abandon their particular views?

And finally, you certainly hold the whole concept of profit in some disdain.  You've mentioned it a number of times, but any exercise that depends upon human cooperation and behavior depends on rewards.  You've got to reward something.

Do you simply dislike rewards that go to investors rather than to the workers and, therefore, can cheer for nonprofit hospitals, even though you and I are now well aware that over the last decade or two not only have hospital workers and administrators seemed to have huge increases in their compensation.  The higher level people now receive bonus packages and salaries in the millions of dollars, ride in chauffeur-driven vehicles and vie with one another for profit with businessmen on trusteeships, board memberships and the like. 

There's money going into these nonprofit organizations, and I wonder whether you think that's the problem.

So thank you very much.

CHAIRMAN PELLEGRINO:  Thank you, Paul.

Do you want to respond, Bud, or do you want to get more questions?

DR. RELMAN:  Let me just make a general observation.  Dr. McHugh raises a whole panoply of basic philosophical and practical questions pertaining to the comments that I made.  It's impossible to deal with them adequately in the time that we have.  I hate to do this, but I beg you to read my book.

DR. MCHUGH:  I will read your book, of course. 

DR. RELMAN:  It's short.  It's easy to read, and it's surely one of the questions —

DR. MCHUGH:  I only had two —

DR. RELMAN:  I understand.  It deals with every one of the questions that you raise.  But let me make it clear.  It's not profit.  Everybody has to in a general sense have a profit in order to survive.  You have to have income greater than your expenses or else you go bankrupt.  I understand that, and it's not profit per se.

What was a revolution in American health care, it occurred over ten or 20 years.  It started in the mid-1960s and by the mid-1980s it was virtually complete. 

What was a revolution was the entry into the health of the medical care delivery system, not the pharmaceutical industry or the medical products or medical supplies, but the medical care delivery system, the entry of investors.  That was the revolution.  That was a new idea, a revolutionary idea, and that changed everything.

I'm talking here though, Dr. McHugh, about what doctors can do.  I didn't imagine that this Council should engage in the problem of how to change our health care system.  I think it needs to be changed radically, but that's another matter.

I thought that you could speak effectively and consequentially to physicians about the ethics of medicine.  If doctors really followed the basic ethical principles in medicine, they would behave differently, and that different behavior would include a more constructive attitude towards changing the health care system.  That's all I'm saying.

CHAIRMAN PELLEGRINO:  Thank you for the clarification.

I have five people wishing to speak already.  I suspect we may have some more.  May I ask for a little bit of conciseness in the questions.  End with a question that is specific and concrete, if possible.

Thank you.

Dr. Gómez-Lobo.

DR. GÓMEZ-LOBO:  Thank you.

Thank you for your exposition.  I think not being myself in the health profession, I think it articulates something like the popular view that we have of how things are getting out of hand.  I think that there is this view that physicians are making this huge amount of money and that there must be something intrinsically wrong with that.

However, relating to the job of this Council, the first question that arises in my mind is when are those profits really unfair or unjust.  I think that that should be for us the leading question, and I'm asking you perhaps to address that or it will be addressed in the next panel, I think, to a great extent.

But that's something to consider because there is, indeed, the feeling also out there that there are many virtues in American medicine and that they should not be overlooked, and I suspect they may have been driven precisely by the fact that so many smart people saw in this field a place where investments would give a return.  So that's my first question.

The second one is this.  Since the problem is huge, what steps, I mean, could be prompted to even get a handle on it?  What would be, let's say, bioethical or moral starting point to say this and this should be done in the face of this overwhelming wave that is breaking over us?

Thank you.

CHAIRMAN PELLEGRINO:  Thank you very much.

Dr. Relman has expressed an interest in having the questions  and then answer several of them as a group, and I think that might be helpful if you wish.

I have next on my list Dr. Carson and then Dr. Dresser, Dr. Meilaender, and Dr. Hurlbut, in that order, and Dr. Kass.

DR. CARSON:  All right.  Dr. Relman, thank you very much for that.  I've heard so many things about you over the years.  It's a real honor to have you with us today.

I agree that there's no question that physicians really need to take control of the disposition of medicine.  We've withdrawn into our clinics and our operating rooms and our laboratories and really have left it to other people, and I believe that that's why we're in the mess that we're in now, and we really have a big responsibility there.

But you know, in terms of what's happening to the way physicians look at medicine, I wonder if we as a society could be somewhat responsible for that.  I think about the 80-hour work week, for instance.  You know, I've noticed since the imposition of that edict that, you know, physicians in training tend to think more in terms of my shift rather than my patient, and if you're thinking more in terms of my shift, then there is automatically the question of what am I getting for this shift, whereas when it was my patient, you knew what you were getting.  You were getting a healthy patient, and there was a wonderful feeling associated with that.

Also recognize that there are certain pressures that have come to bear upon physicians which I think have changed a lot of the way they think.  For instance, when I first started practicing medicine, we didn't have the horrible reimbursement issues that have been imposed by insurance companies.

You know, in the  State of Maryland, for instance, Blue Cross/Blue Shield reimburses at 28 cents on a dollar, very arbitrary; Alabama, 80 cents on a dollar.  Why do they have the ability to do these arbitrary things which impact so significantly upon the way people are able to take care of patients?

In my profession of neurosurgery, the average age of retirement now is 55.  Why has it moved down to that level?  Because it used to be when people reached about 50 years of age or so they wanted to slow down a little bit, but now they don't have the ability to slow down because the malpractice premiums are so high.

You know, in Philadelphia it's $300,000 a year for a neurosurgeon if you've never had a malpractice suit.  You know, these are ridiculous economic pressures which change the way that people look at their profession, and you know, I'm sure that there is some problem associated with physicians, but I think we need to begin to look at some of these outward pressures that have created this situation and maybe address those.  I'd like to know what you think about that.

CHAIRMAN PELLEGRINO:  Thank you, Dr. Carson.

Professor Dresser.

PROF. DRESSER:  Thank you.

I was interested in your views on what professional associations might do to instill, you  know, ethical judgments, normative judgments, standards about relationships with commercial entities as well as other professional issues that relate to the fiduciary role.

It seems to me that, I mean, many of the organizations such as American Academy of Pediatrics and American College of Obstetrics and Gynecology have ethics committees and they issue positions and so forth, but there isn't much effort to educate the members about them or to make them a part of a sort  of notion that this is how we want to practice.  This is what a good physician is, and I would be embarrassed not to behave in that way.

So I wonder about your thoughts on that.

CHAIRMAN PELLEGRINO:  Thank you.

Dr. Meilaender.

PROF. MEILAENDER:I'd just like to get you to think with us a little more about the nature of the crisis that you say you see because there's something about it I haven't got my finger on.

You don't think that seeking or getting a profit is incompatible with altruism just in principle.  You don't think that increased technology is itself incompatible with professional altruism.  You don't think that increased specialization is itself incompatible with professional altruism.  So, you know, exactly why is it that these factors are undercutting professional altruism in the medical profession?

And there are other professions, after all.  Educators make far less profit.  It's not clear to me that professional altruism is stronger there than it is among physicians.  Clergy make far less profit and have far less specialization, and to tell you the truth, it's not clear to me that professional altruism is more common there and that's a profession I know something about.

So you know, if we once grant that these various factors are not incompatible with altruism, then it seems to me, especially when you think about what we as a Council might do, you know, we need somehow to figure out a little deeper about what's going on here.  I at least haven't quite gotten to it and I'd like your help.

CHAIRMAN PELLEGRINO:  Thank you, Gil.

Dr. Hurlbut.

DR. HURLBUT:  My question relates very much to what Gil just said.  You say that M.D.s are at the center of the health care industry and that what's needed is a change of our professional ethos, our restoration.

I teach a lot of pre-med students.  They're very idealistic individuals.  I often tell them to read Lewis Thomas' book, The Youngest Science, as they're heading off to medical school just to get a sense of how things have, indeed, changed.

But it isn't clear to me, short of a kind of larger cultural change, what exactly you're saying is the problem.  An M.D. by the time he's out and actually making a salary has spent an enormous amount of money getting educated, usually has heavy debts, is part of a culture where an equivalently intelligent, educated person would have already been making a lot of money.  I'd like to ask you for some basic facts.

How much does the average physician actually make?  What percentage of the cost of health care is represented by that overall payment to physicians?  And also is this so-called industry actually a profitable industry?  And if so, is that bad?  Does it reinvest itself and therefore improve the industry?

Who then also makes the profit in this industry?

The point I'm getting at is obviously if you're going to have esprit de corps and sustained engagement, the physician needs at least the convenience of having a car that doesn't break down and a comfortable place and safe place to leave his family for long hours when he's not home, and maybe the basic social prestige that comes with some of these things.

I just wonder if the character of medicine may have changed partly because of a general social attitude toward physicians, as well as from within the profession itself.

There was a lot of criticism of the medical profession in the years after I graduated from medical school and a lot of price pressure on physicians.  What are the realities here?  What exactly is going on?

And just one final comment that ties in with my previous comment to the previous speaker.  It seems to me that the society as a whole has become more preoccupied with money than it was when I was a child.  Now, maybe that's just the age I'm seeing the world through, but it seems to me there's an awful lot of emphasis.  Some of our cultural heroes seem to be people who have made a lot of money.  There's a lot of entertainment related to money making.  We seem to want to win the lottery more than anything else in our society now.  There's almost you might call it a kind of drug dealer mentality, that the way to operate in the world is to make a lot of money fast for relatively little in the way of actual service or contribution to the society.

Am I misperceiving this or is this a general cultural emphasis?  In which case, to the degree that physicians are guilty of this, they're just part of a larger ethos.

CHAIRMAN PELLEGRINO:  Thank you, Bill.

Dr. Kass.

DR. KASS:  Thank you, and thanks very much, Bud, for a stirring presentation and for continuing to agitate this question.

I wouldn't deny that the financial incentives and the introduction of investment into medicine produces certain kinds of deformations, though I would comment that other forms of organizing medicine will produce their own deformations, and we'll probably get into some of that this afternoon.

The Wall Street Journal this morning has an article about the so-called better systems where the physicians, in fact, are pushing for a kind of privatization in order to improve the actual care for their patients who wind up spending huge amounts of time on waiting lists.

But I want to come back to the view of the profession internal to the profession as those of you, those of us who educate rising physicians see it and have taught it.  And it does seem to me that 25, 30 years ago when bioethics took up the question of the medical profession, not Dr. Pellegrino who has held the fort on this subject valiantly, but the bioethicists were interested in autonomy, and they attacked professional authority, called it paternalism, and we began to move from a view of a doctor-patient relation as you point out to a provider and consumer-client relation, and that became a kind of orthodoxy.

Granted there were certain excesses that might have invited this kind of correction, but that begins to undermine the internal sense of the profession as a profession, and the profession in many respects caved in and adopted that criticism.

Second, in the definition of what the professional ethic is, you emphasized Freidson's category of ideology doing useful work and ethical commitment to the patient and society.  That's in a way novel for the medical profession, and yet that, too, became part of the ethos and it produces certain kinds of tensions when the duties to patients and the duties to the society might be at odds.

And I guess when Gil spoke he talked about professional altruism.  That seems to me too woolly a notion for what we're talking as the ethic of the profession of medicine.  Aren't there certain profession specific ways to describe what it is the physician swears an oath to, which used to be sworn?

In other words, what are the particular profession specific norms that ought to guide and govern?  It can't simply be this loose thing called altruism rather than self-serving, but one has to talk about I will use my knowledge for the benefit of the sick.  I will not give a deadly drug if asked, and so on.

In other words, it seems to me the profession has abandoned the attempt to articulate its own profession specific aspirations, and I doubt that you could get the physicians under 40 and the physicians over 60 to sit down and give a comparable account of what the guiding internal norms of the professions would be and what the boundaries are that they ought to have.

So I wouldn't lay this all at the blame of external pressures and profit motive, but I think there has been a kind of failure of the profession to understand itself and to pass down that self-understanding and training, and I wondered if you'd comment.

CHAIRMAN PELLEGRINO:  Thank you.

Dr. George, and then I will ask Dr. Relman to respond, and then there may be more questions after that, but I think you've got plenty to respond to at the moment.

Robby.

PROF. GEORGE:  Thank you, Dr. Pellegrino.

And thank you, Dr. Relman.

In listening to your remarks, I was struck by the similarity of your concerns and warnings to those I've heard expressed by senior and distinguished people in the legal profession about the situation in that profession.  I myself was trained in the first instance as a lawyer and was briefly in full time practice, and I've kept a hand in ever since, although my own vocation has been as an academic.

One of the — certainly the finest lawyer and one of the finest men I've ever know is a man 87 years old now named Wiley Vaughan, Herbert Vaughan.  He was with the firm of Hale & Dorr in Boston for many, many years, very distinguished, very successful, made a lot of money.

But as he was wrapping up his career and going into retirement, he said to me something that struck me at the time reflecting on the situation with law as a vocation in the early part of his career and moving more in the direction of being a business in the later part.  He said that he was glad that he was at the end of his career in the law rather than at the beginning because he was able to practice at a time when law truly was a client oriented and helping profession, and it just wasn't that as far as he was concerned anymore.

So I am struck by the thought that what you say about medicine can be said not only about law, although of course with interesting differences, but probably about other professions within our society as well.

I wanted to ask some questions that were specific to your remarks though.  One, I wondered about the phenomenon that you described and even gave us a sense of the historical timing of, of the marketization of the delivery of health care by the movement into the process of investors.

I'm wondering what do you see, if any, as the pros of that that are to be weighed against the cons that are pretty clear from what you've said and from what some of our colleagues here who are doctors have said.

Two, is there any realistic chance if a judgment about the pros and cons in the end comes down in favor of abandoning that or getting rid of it or going back on it if possible; is there any realistic chance of changing it in a way that won't cause more harm than good?

And third, I was wondering about what you perceive as the effect of the new system with investors playing such an important role on who is attracted into the medical profession and on whether it makes a difference as to how many people are attracted into the medical profession. 

Is the weight of people or the numbers of people who are aspiring to careers in medicine different now than they were in an earlier period of time when medicine was different or not? 

And either way, what would account for either there being a change or there not being a change in view of the dramatic difference in the profession that you've described as a result of this marketization?

Thank you.

CHAIRMAN PELLEGRINO:  I'm going to ask Dr. Relman to respond.  Up to this point, Carl, I saw your request.

PROF. SCHNEIDER:  I have a brief follow-up.

CHAIRMAN PELLEGRINO:  Is it brief?  Okay.  I believe you.

PROF. SCHNEIDER:  Yes, it is brief.  I just wanted to pick up on the point that this was a phenomenon in law as well.  Let me read to you what the Chief Justice of the United States said on June 15th.

"More and more the lawyer must look for his reward into the material satisfactions derived from profits as from a successfully conducted business rather than to the intangible and more durable satisfactions to be found in the professional service more consciously directed toward the advancement of the public interest.  The commercialization of law has made the learned profession of an earlier day the obsequious servant of business and tainted it with the morals and manners of the marketplace in its most anti-social manifestations."

This was said by the Chief Justice of the United States on June 15th, 1934.

All of us people over 50 here are looking back at an edenic past and saying how much worse things are now.  There is a study of lawyers between 1925 and 1960, which marks five different crisis periods in which exactly these words are used to describe what is happening in law, and the author of the study says that in the 1890s much of the same rhetoric can be found. I suspect it can be found by lawyers working under the Code of Hammurabi.

So I just raise a cautionary note about whether or not we are accurately describing real changes.

CHAIRMAN PELLEGRINO:  Thank you very much, Carl.

There will be time for further discussion after Dr. Relman responds to that large number of very important and interesting questions.

Bud.

DR. RELMAN:  Well, I want to thank the Council very much for the really probing and challenging questions.  They're all important, and I'll do my best to be brief.  And forgive me if I don't deal with every aspect of the questions that you raised.

When are profits unfair?  What's the value of profits?  I want to make it clear again that it's not profit that I'm concerned about.  I recognize I use the word "profit."  I should have used the word "investor owned." Profit really means monetary gain from one's work, and everybody has to have that or else you're working as a slave or in the Army or for the government.

I'm not opposed to profit.  It's not profit.  It's investor interest, and the reason that investor interest is bad is somebody said what are the pros.  There are no pros as far as I'm concerned.  It's bad because investors, as defined by the gurus of economic theory, by the Milton Friedmans of this world, investors expect a gain from putting their money into something, and the people who are in charge of that money, that is to say the managers, the administrators of the investor owned organizations in health care have an obligation to see that the investor's money gains something.

The purpose of investment is not to produce a particular product.  It's not to take care of people's health care needs or to make American society healthier.  It's to make more money, and I don't think that that has any role in health care.  I'm all for investment in many other parts of the American economy.  I invest myself.  I'm not a hypocrite.  I hold stocks.  I believe in capitalism.

But I do believe that as some very smart people have argued before me that there are parts of the American economy or American society in which investment is not a good idea.  It doesn't work.

Now, probably the first and the smartest person to talk about the inappropriateness of the market principle and the investment principle in health care was Kenneth Arrow in 1963.  For those of you who want to argue with me about the value or the usefulness of profits and what's wrong with investment, read Kenneth Arrow, 1963, American Economic Review, a very thoughtful, penetrating, not the first time, but a devastating analysis of market failure in health care.

He came to this fresh.  He never thought about health care before.  He was developing some theoretical analysis of welfare economics as applied to health insurance, and he thought about should there be a medical market.

And you should read..  There are about — I don't know — five or ten pages in that lengthy and very difficult economic analysis in which he devastatingly takes apart the concept that market principles apply to health care.  They do not; they cannot; and they should not.

That's my position.  That's the position of many people now, including some smart economists like Thomas Rice at the University of California.  I believe that investor ownership should have no place in American health care.

Can we get rid of it?  Would it be devastating?  Would it be unrealistic?  It would be difficult, but it can be done, considering the amount of money we spend on health care and considering the cost to the health care system of investor ownership.  We can afford to buy out investors, make them whole.  Give them the current market value of their money and say, "We suggest you take your money and you invest it in timber, in oil, in solar energy or whatever you want to invest it in, but not health care."

That's my position.  Now, Dr. Carson talked about external factors, changing doctor's views.  Of course; of course, the doctor's professional commitment has been battered by all of these external forces that are impinging on it.  That's why doctors should be in the vanguard of advocating change.

I devote a chapter in my book to talking to doctors and saying here's why it's in your professional interest and in the interest of your patients and in the interest of American society to change the system so that you won't be forced by all of these external factors to behave in ways that are not consistent with your professional commitment.

Professional associations, what can they do?  Dr. Dresser asked me that.  I think they can do a lot.  I do not imagine that the medical profession's involvement in health care reform will sort of spring spontaneously from grassroots.  It will have to be led by professional associations that have some commitment.

Now, there are some professional associations that are concerned about changing the health care system like the American College of Physicians, the American Academy of Family Practice, the American Academy of Pediatrics, and there are some professional societies which have taken traditionally a much more conservative view, like the AMA.

But I think that professional associations do have an obligation to lead the way, to lead discussion.  I say this to doctors.  You are trained to look at data.  You are trained to look at evidence, good or bad, pleasant or unpleasant, and make reasonable decisions to maximize the utility — I'm talking like an economist now — of your patients and American society.  Look at the facts.  Look at the facts.  Look what's happening to the American health care system.

Somebody said — I think, sir, you said — we've had crises for 100 years.  Everybody thinks it's a crisis.  Never in the history of American health care were we at a situation where we are now.  What's different?  What makes this situation unique?

Never has the American health care system taken 16 and a half percent of our economy and unless something drastically happens is predicted by everybody who's qualified to make such predictions to reach 20 percent in ten years and maybe 30 percent after that.

Now, it can't go on.  That's not ho-hum, more of the same.  That's a dramatic change in the amount of the American health care economy committed to health care, and at the same time never, never has the health care system been so wasteful.

I mean, it's true.  For many, many years the American health care system wasn't very effective.  We couldn't do very much, but along about, you know, as Henderson said, along the early part of the 20th century the American health care system got good enough so that it was a better than 50-50 chance that a doctor-patient encounter would benefit the patient.

Throughout the 20th century, we were benefitting patients reasonably efficiently.  There's a lot we were dumb about.  We didn't understand.  We did things that didn't work, but gradually we've done a lot to help patients.

Now, for the first time, I conservatively estimate — and I'm not the only one to make this estimate — that maybe as much as 40 percent of the $2.2 trillion we spend on health care is wasted, is not buying us anything useful or productive.  The evidence is overwhelming that we're wasting huge amounts of money.

Well, that's a crisis.  I trained in all my life not to cry "fire" in a crowded theater.  I'm a very conservative, evidence-based person.  We are now facing a crisis, and if doctors don't recognize it, who will?

Maybe Rick Wagoner, the president of General Motors, will recognize it.

Dr. Meilaender, you said that I mentioned all these factors that were not incompatible with professionalism.  So why is there a problem?

Well, yeah, they're not incompatible with professionalism if the profession behaved consistently with its values.  It could deal with all of these problems, but it is being lured away by money, by economic pressures and by a general change in attitude.

But money is the main problem, and somebody said everything is driven by money in this country.  Health care unfortunately now follows the money, and doctors come out heavily indebted.  They see there are enormous differences, far greater than ever before between the kind of life and the kind of income that specialists can command versus primary care doctors, and people are fleeing primary care by the thousands, and there's a crisis, yes, a crisis in primary care.  Nobody is going into primary care anymore.

If you don't think there's a crisis, I suggest that you go to any number of American cities as a newcomer.  You've just moved there and you want to get an internist or a family physician for your family, for you, to look after your general health and advise you about what specialty services you need.

Good luck to you.  All over America now you can't find internists anymore.  They're disappearing.  Why?  They're all becoming specialists.  Why are they becoming specialists?  Because per hour that they work they make far more money as a procedurally oriented specialist than in primary care.

The system is broken, and it needs to be changed.

What percentage of health care costs go to doctors?  Dr. Hurlbut at Stanford asked that.  I can give you an exact number.  Gross, before all expenses are paid, before malpractice insurance, retirement pay, office expenses, between 20 and 21 percent, and that's fairly steady over the years, increasing just a tiny bit.

Net, after you pay all your expenses or practice, including retirement benefits and your staff and blah, blah, blah, around 11 percent.  That's the number.

Is the health care industry profitable?  You bet.  Why would there be this great rush to put investment; why are there health care investment funds?  Everywhere you look in health care new businesses are springing up because of the opportunities to make money.  That money that the health care for-profit industry takes out of the system is for the most part not contributing to health care.  The private, for-profit, investor-owned health insurance companies, they are the majority of private health care insurance companies in this country.  Before they pay the providers, before they pass their money along to doctors or hospitals, they have taken out of the premium that they've collected anywhere from a minimum of ten percent — that's the lowest amount I've ever seen — to a maximum of around 25 percent.

Add to that the added cost that they lay on the providers.  The Massachusetts General Hospital 30 or 40 years ago used to have a relatively small office for billing and collecting.  Now to deal with the hundreds of insurance plans and all of the rules and regulations, they have several hundred people employed by the Mass. General at huge cost to the hospital because of the insurance system.

So that everywhere you look private business — I'm not opposed to private business, but in health care it doesn't belong.  Why?  Because health care is a social need.  It's not part of the regular market, as Arrow said.  It cannot be controlled by consumers once.  It does depend on needs.  It is need driven for the most part, and the ordinary controls between supply and demand that determine how much money we choose to spend on computers or automobiles or clothing or food don't apply to health care.  For the most part, when you're sick you're sick.  You've got to take care of it or it has got to be taken care of, and you're in no position to — I never met a smart consumer in an intensive care unit or the operating room.  I never saw anybody shopping around for a cut rate brain surgeon.  It doesn't happen in health care.

So it's different, and all of that money is taken out of the health care system.

Dr. Kass, you said we caved in to the consumer.  We certainly did.  Of course we did, and doctors did and the whole country has.  We've bought into the idea.  From the White House down to ordinary citizens, we've bought into the idea that consumers of health care have some wisdom which will enable them to decide what health care they need, when they need it, and what price they should pay.

It ain't so.  It's just not so.  And so, yes, we have given in.  Of course there are M.D. specific norms beyond altruism and we've abandoned them.  The problem is not all due to commercialization, but a lot.  Of course, there are other things, too.  Medical technology drives you to behave in a certain way.  But commercialization is a large part of the problem.

Mr. George, the law also suffering a decline?  Of course, and you know, true, many of the things that were said about law were also said about medicine in the 1930s and the 1940s, but it's different now.  It's different now for the reasons that I've given.

And I say if you don't believe that we have a crisis, you haven't been involved in health.   You've been lucky.  You've not been sick and nobody in your family has been sick.

I can't see how anybody in America can say we don't have a health care crisis who ha had to deal with the health care system.  Of course it's in crisis, and we have to look, I think, honestly at what causes it.

Part of that crisis is that the change in the health care system has changed the behavior of doctors.  Yes, doctors have caved in.  They're only human, and they're not smarter or better than the average educated person in this country, and yes, they've caved in.  They've made terrible mistakes, but I think it's time for us to change.

I really hope that you members of this Council will think about what you can do not to change the health care system.  That's not your job, but you could start a dialogue.  You could issue statements which would stimulate discussion in the medical profession and in the public about what doctors ought to be doing, what ought to motivate doctors.  What are the ethical principles?

Now, it's not very complicated.  The AMA had it right.  Up until 1980 go read the ethical guidelines of the AMA.  I often criticize the AMA for being too conservative and too highbrow in many ways, but they had it absolutely right about what doctors ought to do. 

Until 1980 they said doctors ought to make their living by taking care of patients, not by investing in the facilities that they work in, not by making deals with drug companies or device manufacturers, and they said doctors are not like business people.

It isn't that business people are worse.  It's just that they're different.  Business operates by different rules and different expectations.  When you go to see your doctor and you're sick, expect and you need to be able to expect that that doctor puts your interest, your medical needs ahead of his or her own financial.

When you go to buy a used car or you go to buy a computer, you don't expect that the computer salesman or the used car salesman is going to think first about what's really best for you, what you need.  He or she is going to sell and sell and sell and sell.  The law says they have to be honest.  They can't lie to you or they're not supposed to.  They're supposed to give you an honest product, but they have no obligation at all, and they're not supposed to have any obligation to consider your welfare out of their own economic situation of their companies.

It's different in medicine, and I say that anyone who doesn't recognize that difference is missing the boat and is contributing to the crisis, and I have no doubt.  I have no doubt that the crisis, if unattended, if doctors don't change, if the public doesn't change, and ultimately if government doesn't change, the crisis is going to result in implosion of the American health care system.

Thank you.

(Applause.)

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Relman.

I think we can get back on track now with the change in our schedule.  We'll break for lunch now and return at 1:30 for Dr. Sullivan who has overcome at least in part the weather blockade that he was involved in and kept him from getting here this morning.

So thank you very much, Bud, and thank the Council for your participation.  One, thirty back here.  This time we're back on the strict schedule.

(Whereupon, at 11:51 a.m., the meeting was recessed for lunch, to reconvene at 1:30 p.m., the same day.)

SESSION 2: THE PROFESSIONS IN CONTEMPORARY AMERICA: PROMISE AND PERIL

CHAIRMAN PELLEGRINO:  When we began I forgot a very important official act, and that is to recognize Dr. Daniel Davis, the Executive Director of the Council, the man who makes things work.  It's important for this to be a government properly run meeting to announce him as the Executive Director and the official representative of government.  I'm simply a peon who gathers the group, but he is the Executive Director.

Thank you, Dan.

And this applies retrospectively.  The only power I have is to say my statement applies retrospectively.

This afternoon we pick up the program, and we're very, very grateful to Dr. William Sullivan for putting up with the rigors of air travel.  As I said at lunch, the motto for air travel these days is time to spare, go by air.  I hope you had some time to spare, but at least you're here with us, and we're very, very thankful.

Dr. Sullivan is Senior Scholar of the Carnegie Foundation for the Advancement of Teaching, and he is going to address the topic of professionalism from a more general perspective rather than in relationship to any particular profession or set of professions.

Dr. Sullivan.

DR. SULLIVAN:  Thank you very much for also the indulgence in rearranging schedules at the last minute.  This was a bit of an adventure for me, and I want to make it clear this was not an ill conceived idea for a dramatic entrance.  It was really due to United Airlines and some thunder storms in Chicago last night.

But it's actually a pleasure and certainly an honor to be invited to speak on the topic of professionalism, a topic that I think is of great contemporary importance before such a distinguished body, and I'm grateful for that opportunity and honored to have been invited.

The main theme that I want to stress this afternoon is what I want to call the practical necessity for professionalism, specifically for what I'm going to call a civic professionalism for the public good.

I think this argument supports a vision of the health professions, in particular, but I want to frame it in a way that applies more broadly to many professional domains, including law, the ministry, education, engineering, architecture, accounting, and the sciences.

I will proceed in three steps.  First, I want to provide a general characterization of the professions and the ethic of professionalism.

Second, I want to focus on professionalism in two senses, first as a heritage, and second as a moral source to guide thinking about contemporary professional work.

Third, I want to address the question of how to strengthen professionalism in today's climate.  Here I will talk briefly about the challenge of professional education.

Finally, I will conclude by underscoring the intrinsic good of civic professionalism as a complement to what I believe is its manifest practical utility.

So first, the professions and the ethic of professionalism; second, professionalism as heritage and as moral source; third, strengthening professionalism; and fourth, integrity and civic professionalism.

To assume a professional identify is not only to join an occupation.  It is to take up a civic role.  The core professionalism is that by functioning as a lawyer, engineer, doctor, accountant, architect, teacher or nurse, an individual carries on a public undertaking and affirms public values.

With this identity comes a certain public status and authority as is granted both by custom and the profession's social contract.  But professionalism also means duties to the public.  Chief of these duties is the demand that a professional work in such a way that the outcome of that work contributes to the public value for which the profession stands.

The larger public, I would submit, seems to understand this intuitively.  There is widespread expectation that professionals should be accountable beyond the measure of profit and loss because the professional ethic rests upon a fiduciary basis.

Amid the general outcry over the revelations of fraud and malfeasance as the financial bubble exploded in 2002, the sharpest outrage was directed at the law and accounting firms.  Quite correctly both officials and the public at large saw the leading lawyers and accountants of those organizations as guilty of an insolent repudiation of public trust.

They, therefore, judged those professionals corrupt and so more odious, if not more reprehensible, than your business leaders of companies like Enron and WorldCom.  Like hypocrisy, moral outrage is premised upon accepted standards of value.

The ideals bound up with professionalism have been only imperfectly realized in any professional field, but the persistence of these at least in the form of aspiration is noteworthy.

Summing up a large literature, the historian Shelton Rothblatt writes that professions can be defined by an ethic of service.  All agree that education, whether by apprenticeship or science, has been the central feature of professional identity.

Equally true, I think the professions can be seen as highly skilled occupations with a distinctive corporate form of organization.  But they are more than this.  In their corporate organization, they represent a project for bringing into the marketplace and society the spirit of public service.

Professions are organized so that individuals must submit to the corporate organization in order to acquire their specialized skills, and equally important, can only benefit personally from the employment of this human capital by applying it according to standards that are established and in aspiration, at least, monitored for the public benefit.

Of all job categories, professions and professionals have traditionally shown the greatest degree of involvement in their work, along with the largest attachment to its intrinsic rewards in contrast to the rewards of income and status.

In many ways then, the professions have, indeed, provided models of good work.

Professions operate within an explicit contract with society at large in exchange for privileges, such as monopoly on the ability to practice in specific fields.  Professions agree to provide certain important social services in exchange for the privilege of setting standards for admission and authorizing practice.  Professionals are legally obligated to discipline their own ranks for the public welfare.

The basis of these contracts is a set of common goals shared by the public and for which different professions undertake responsibility.  So medicine, nursing, and public health are, in effect, chartered for the maintenance and improvement of society's health, just as education exists to promote the goal of an educated citizenry, law to secure social justice, or engineers to insure safety.

The roots of this ethic, as I will try to show, lie deep in our society's religious and civil heritage, but these are public values.  In economic parlance, they are public goods, meaning that they are values from which all benefit and which depend upon everyone's cooperation, but to which no individual market actor has a strong incentive to contribute.  The professions are publicly charged to make it their primary concern to sustain such public good.  They are, therefore, in an important sense public occupations even when they work outside government or public supported institutions, such as schools and universities.

Like other institutions oriented for the public, professions depend upon trust and good faith on the part of both the public and the professional groups.

Now, it's this social contract, especially its larger implicit basis in social trust which has frayed, I believe, in recent decades.  There's ample evidence of the weakening of public trust in many professional areas, including the ministry, law, and teaching, as well as medicine.

Analysts, such as Derek Bok have pointed out the great shift in compensation and also prestige within professional ranks which has taken place since the 1970s.  The trend, according to Bok, has been away from public sector employment, such as government and education, toward the service of business and private sector activities.

One major result has been the growth in income disparity within professional ranks, directing the paths toward both wealth and prestige into the profit making arena and away from public institutions.

Sociologist Steven Brint has summarized these developments of movements away from what he refers to as an earlier form of professionalism as social trusteeship toward the embrace of a notion of the professional as the purveyor of expert services in an increasingly stratified and competitive marketplace.

I have referred to this as a shift from a civic toward a technical conception of the professional enterprise.  This social climate has put the professions on the defensive.  It has led many to question both the value and viability of the professional organization of work in many fields.  Indeed, the professions might be seen as facing a continuing low grade war of attrition. 

Professionals have traditionally been ascribed vocations, as well as careers or jobs.  However, while the value of having a calling is still respected today, it is seen mostly as applicable in very restricted spheres. 

So apart from the distinctly religious sense of calling, it is widely understood that both in the arts and in the sciences contributions of value require nothing less than the whole of a person's life and devotion. 

But the idea of institutionalizing vocation, of making it a regular established feature of daily work, as in professional occupations, is today a more questionable proposition.

To sum up, there has been some loss of both understanding and appreciation of the value of professionalism, but more serious is the erosion of the public's trust that professional groups are serious about these purposes.  It is not that assertions of good faith on the part of the organized bar or medicine, for example, have been lacking in recent years.  Rather, the public has seen these professions as gestures which must be redeemed by concerted action.

What seems missing is the public leadership involved in solving perceived public problems, including the problems of their own abuses of privilege and refusal of public accountability. 

Now, these issues point to the essential civic dimension of professional life, where the levels of trust, self-restraint, and degree of cooperation are high, where social interactions include most parts of a social environment on an equitable footing and are perceived as mutually beneficial.  Professional organizations and individual practitioners are more likely to behave as good citizens, taking responsible often leadership roles in the society's life.  This is the kind of thing which Brint's avocation of social trusteeship is a gesture toward.

In return, the professions maintain goodwill, public support and often prestige.  In such circumstances, individual professionals are likely to find their efforts of integrity recognized and rewarded.  These are the conditions of a society experiencing a kind of positive interdependence among its parts.

Conversely, however, where civic cooperation falters or becomes  sporadic, mediation between individual goals and social need is likely to break down, releasing aggressive efforts to escape social responsibility with all the corrosive effects this has upon democratic life.

A direct consequence of such circumstances is the worsening of possibilities for integrity in professional life.  Many of the disagreeable aspects of contemporary professional activity have their root causes, I believe, in this experience of negative interdependence.

From this perspective then, the professional enterprise is an important modern civic institution.  The professions have pioneered and continue to model a socially attuned way to organize work, thereby providing a potential resource through bringing the concerns of citizenship into a wide variety of specialized occupations.

The integrity of professional life — indeed, its future — is, I think, bound up with this civic enterprise.

Second, professionalism as heritage and as moral source.  Today the professions seem a natural and established feature of American society as in all developed nations.  In fact, however, the professions' achievement of social importance was hardly an expected or necessary feature of the development of the United States. 

There are ways in which the professions have fought an uphill battle against the ideals of individualism and egalitarianism so prominent in our democracy.

The conflict between the meritocratic ideals of the professions and a broader egalitarian populism has led to dramatic swings at one moment toward public recognition of the competence of certain specialized groups to regulate an occupational sphere, such as health care, while at other moments public opinion has stripped occupational groups of any special prerogatives or privileges.

Since the professional career has always been a route to individual success, professions have been focal points in the struggle to balance democratic openness to individual achievement, on the one hand, with the need for the professions to be trusted to work for the benefit of society in pursuit of agreed upon common ends.

Professionals take part, as I've argued previously, in commercial society, but they do so as the owners of a special type of property or capital of a peculiarly intellectual sort, the skills and knowledge acquired through their specialize training and experience.  This is sometime referred to as "human" as opposed to "physical" capital.

Like physical capital, human capital can be traded and like physical capital its security and negotiability depends upon a structure of legal definitions and procedures.

But the human capital of professionals is peculiarly depending upon the public legal acceptance of the value of services offered by the professional.  The professional's services are often beyond the lay buyer's ability to understand or fully judge.

There is, thus, an inescapable, reciprocal fiduciary relationship necessary between professional and client.  That is, the professional, including the group of professionals providing a certain service, must persuade clients to accept the professional's definition and valuation of that service even as the clients must acknowledge and trust the competence of the providers.

In this way, professionalism is always the result of a two-way process of social and political accommodation.  More than many other kinds of property, the human capital of professionals is visibly a social and, indeed, political artifact.  Hence, it can only be secured so long as, in the main, the terms of reciprocity seem fair to the public or the profession seems to be able to wield power to uphold its privileged position.

In this sense, the professions live a precarious existence in a democratic society, and I think it's for this reason that the ethic of professionalism has been so crucial in the development of professions in the United States.

It's Bruce Kimball who has traced the development of what he calls the true professional ideal through three historical stages, through a highly contingent process which only looks inevitable in hindsight.  Kimball shows how being a professional came to require the trades today most often identified by social scientists, for example, in studying professions.  That is, a profession is an occupation it's often said based upon formal knowledge and trained skill, organized in a collegial or guild-like way, and carried on in the spirit of service.

Kimball's work shows that the combination of knowledge and service came first, and this really lies in the fact that the first of the organized professions in America with high prestige, the one that approximated to what he calls "the true professional ideal in its time" was the ministry.  And this was in direct continuity with the medieval university, argues Kimball.

The minister in colonial and early republican America enjoyed high intellectual and social prestige and clergy were educated and credentialed in colleges such as Yale, Harvard, and what later became Princeton.  The ministry helped define what theologians at the time called dignified professions, continuing the medieval notion of profession as a religious calling to divine service.

In the new American republic, politics and law acquired enormous prestige through their central role in the new revolutionary order, and here Kimball argues we see a migration of the true professional ideal from the ministry to the law.  And it is from the law that the notion of vocation as marked by political and legal learning rather than theology derives.

In a constitutional order informed by theories of social contract, professional service came to mean contractual relations between a professional and a client.  The legal profession early organized itself into voluntary associations of the kind Alexis de Tocqueville saw as the distinctive feature of the American polity.  Yet it was still to be informed by the earlier ethic of selfless service.

These bodies of practitioners pledged themselves to both high standards of learning and to an ethic of public service.

The third stage in this development, Kimball argues, began early in the 20th century which saw a new configuration of prestige crystallizing around the natural and experimental sciences.  The sciences were then being institutionalized in the new American universities, and scientific expertise was beginning to shoulder aside legal and theological learning as the exemplary form of intellect.

As a result, first the professor as the expert within the new university system and then the scientifically trained physician emerged with new claims on the term "professional."  These claims were based upon the growing mystique of scientific knowledge.

In Kimball's account it was that notion of the professional which finally emerged a century ago that has become normative for Americans.  The professional, that is, was learned, but especially scientifically trained in a university setting, licensed, supported by a collegial organization of peers, and professed to an ethic of service both to clients, the legal inheritance, and the public, the inheritance of the ministry.

Now, these, of course, are ideal types.  They have never been realized in practice in any full sense, as I've tried to suggest.  But they have functioned, I think, as very important to the legitimation and, in fact, the guidance of professional life.  It's in that sense that they can be called moral sources.

The term "moral source" has been introduced by philosopher Charles Taylor, and I think it speaks well to the problem of professionalism today.  Taylor notes that increasingly modern moral problems involve not so much concern about heavy moral demands rooted in divine commands or nature, but rather the experiences of anomie and alienation when, as he puts it, the world seems to lose altogether its spiritual contour, producing a kind of vertigo, a fracturing of our world, even our sense of bodily integrity.

In order to maintain the sense of coherent identity and to act responsibly under such conditions, Taylor argues, it is essential to discover ways to articulate our sense of what is important and orienting for our lives, to articulate a sense of life, a framework for meaning.

Professionalism, as I've been arguing, is such a framework for meaning.  It provides an understanding of basic and determining values.  What professions should be, how professionals should conduct their lives; it provides the taken for granted expectations and norms about what is normal and desirable in the life of medicine, nursing, law, teaching, and so forth.

If Taylor is correct, the capacity of professionalism to inspire and guide individuals and professional groups depends upon its influence in shaping imagination and perception, in shaping the basic habits of professional life.  But normal sources become most effective when they function within ongoing institutions that echo and embody these moral meanings.  These institutions and their personnel become in a sociological sense carriers of the moral sources which they articulate.

What I have tried to suggest earlier is that it is just these institutions and their function as carriers of the ethic of professionalism which has been experiencing a kind of low grade erosion or slow crisis.

Therefore, my third point, the importance of strengthening professionalism.  It's not exaggeration, I think, to say that education remains a dominant feature of professional life even long after professionals leave the formal phase of training.  In order to make professionalism effective as a moral source revitalizing professional work, the connections between formal preparation and later experiences of practice have to be rethought for our time with perhaps a new emphasis upon the formative processes of professional life and education.

This will require more integration, more continuity between the concerns of the academy and those of the practitioner community.

In order to do this, however, it is important to recognize the complex and hybrid nature of today's preparation of future professionals.  The complexity of this problem, I think, can perhaps best be seen by recalling that professionals are trained in universities or university-like settings, and this is a process that began about a century ago, the movement of the professions into the university for reasons that Kimball's description of the new prestige of the universities and the sciences, I think, helps explain.

But it's important to recognize that once in the university, those who train future professionals now acquire a kind of dual identity, perhaps one might say a dual allegiance.  They are professors of law or medicine, but they are first and foremost professors of law or medicine.  As such, it is in many cases the values and the, to use another sociological barbarism, the career structure of the academy which dominates many professional lives.

This acquires importance because of the academy's own internal emphases.  The academy focuses, as I  think I don't need to elaborate, upon the development of systematic abstraction.  The great contribution of the modern university has been the development of modern science and a host of disciplines and subdisciplines in which this process of taking specific incidents and events and turning them into general rules and laws has been carried to an ever greater degree.

This is important, or at least we believe that it's important in most forms of professional preparation.  It's important to note, however, that professional education has its roots in a very different kind of experience, which is to say the experience of apprenticeship; that if we go back beyond a century ago — the case of medicine we actually would have to go a bit further into the 19th century, but in the case of law we don't have to go much further than a century — we discover that most professionals actually acquired their skills and knowledge and were admitted to their guilds largely on the basis of apprenticeship, which is to say that they learned and were socialized into their professions through the guild of practitioners.  In some nations this is still largely true.

In the United States, however, the practitioner guild, if we could call it that, has in many ways been held at arm's length by the academy.  This varies from field to field, but the mark of this, I think, is the enormous prestige given to academic research which in almost every field trumps clinical experience as the key denominator of prestige and importance.

So whereas once the aspiring professional met a kind of unified apprenticeship, often probably rather narrow and perhaps not enormously developed, today's professional student meets what I refer to as a kind of fractionated apprenticeship, at least three different kinds.

That is to say there is the apprenticeship of theory, which I've attempted to very briefly describe, but there is also very importantly the apprenticeship of practice.  And in medical education, this is very clearly marked by movement from one kind of educational experience to another, the traditional beginning of medical education in laboratory science and then the rather abrupt transition into the world of clinical practice.

But to this I think we have to add yet a third sort of dimension of apprenticeship, which was integral to the old unified form but which today is largely split off from both the academic or intellectual apprenticeship and the apprenticeship of skill in many cases, and that's the apprenticeship of professional purpose and identity.  This is the apprenticeship about which the public often is very concerned, but which necessarily, I suppose, in the logic of the academy, tends to receive the least attention.

So the argument I would like to put forward is that the route to strengthening professionalism and, therefore, of guiding or renewing the guidance of professionalism over professional life has to lie in the redevelopment and strengthening of the relationship among these three dimensions of today's professional apprenticeship.  And that is a task that will require the cooperation of both the academy and the practitioner wings of these fields.

Which brings me then to my conclusion, which for the sake of time I think I can state now rather quickly, namely, that in modern civil society no group or institution enjoys permanent guaranteed status.  Social relations remain open and fluid.  Professions compete with other professions and other organizations sometimes to the benefit of society and sometimes not, but what matters decisively is the prevailing climate in which this competition goes forward.

In this important sense, the whole, I think, is more than the sum of its parts.

The peculiar strength of strong civic cultures is, in fact, this holistic effect of widespread and pervasive forms of public cooperation.  The professions are integral parts of this process in the United States, and today's professions face, I think, not only changing domains of knowledge and shifting fields of practice, but also shifting conditions of practice within the dynamic and often confusing society.

Therefore, the horizons of the professions and particularly of the leaders of the professions need to be broad.  Petitioners must be able to think critically about their own situation and that of their field in relation to its defining purposes, and it is there that the ethic of professionalism and the elaboration or articulation of that ethic for new situations becomes critical.

To this end, the institutions or professional education, I think, must be made to model this and also to be better and more effectively linked to the later development of practice in its many dimensions.

So professionals above all need the ability to integrate a critical yet engaged standpoint into their guild's particular sense of knowledge, craft and attitude.

To preserve the professional social contract, we need to bring the perspective of the aware and critical citizen into the formation of the members of the community of practitioners.  The opposing poles of specialized expertise versus the broad sympathies needed for active citizenship define the tensions of professional life in our time.

But through its own inherent logic, a civicly attuned professionalism proposes an ideal of self which complements the need to achieve a positive outcome in today's growing social interdependence.  That ideal corresponds in one important way to the aspirations of the pervasive search for self-actualization and takes it beyond itself.  It demands of the individual a high degree of self-awareness and a major effort to develop one's powers, and these have been among the strongest contributions of professional life to our society. 

But then it demands more.  The goal of self-actualization itself must be transcended or perhaps better reoriented by integrating the goals of the individual practitioner with those of the larger professional community and, indeed, of the larger society.

The logical fulfillment of this process is a kind of character for whom what happens to these larger commitments is as important as what happens to the self or perhaps even more so.

This, I then would propose, is the outline of a kind of integrity of modern professional life, one which remains a viable possibility even if under heavy stress, and it's one that I think we have in time the opportunity to commit ourselves to anew.

Thank you.

(Applause.)

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Sullivan.

We have asked first Carl Schneider to open the discussion.

Carl.

PROF. SCHNEIDER:  First I want to say how very glad I am to have been asked to do this because I have been reading Dr. Sullivan's work almost since — this can't be true.  You're much too young for this — almost since I started teaching law.  Reconstructing Public Philosophy was a book that I read with pleasure and profit and still think about, which is remarkable considering how few of the books that I've read I can even actually remember how they read.

Let me start off.  I think I need to by saying that I believe in professionalism just as much as anybody in this room or this country, and that I believe it in many ways to be much more alive and well than many of the pessimists who have spoken so far today.  I know lots of members of both the legal and medical professions who strike me as embodying the nobler qualities that we look for in professionals.

I'm also puzzled that there is so much concern about how difficult it is to be truly professional.  It was never supposed to be easy.  Straight is the path and narrow the way.  Professionals always have operated under the kinds of economic pressures to go wrong that people are worried about now. 

Justice Holmes almost a century ago asked the graduating class at Harvard how they could hope to find a way of living greatly in the law when they to realize that law was a business, and he said it isn't easy, but it is possible.

The last prefatory remark.  I'm getting very nervous as a historian manqué about all of these historical generalizations.  I said something about it before lunch.  Let me say one more thing about it now.  I think in many ways the ethical standards we hold out for professions are higher than they used to be.  We may have just as many defaulters, but they may be defaulting from what is in some ways a higher standard.

Now, let me say that I'm responding here primarily to Dr. Sullivan's article "Markets v. Professions," because that's what I had to study before I came.  I want to suggest that the discussion may be helped by a higher degree of exactness, concreteness, and consideration of context.

So I'd like to begin by suggesting that one of the questions we need to be asking is: what is the problem that professions are facing exactly?  We have heard in a variety of forms, in the article I'm commenting on, and earlier today that the market is in some way disturbing our ability to be adequately professional.  But how exactly is that working?

One of the suggestions — this in the article — is that professionals have lost the confidence of the public and their trust, and that they are competing with people who are not members of the profession because professions have lost their professional authority.

Professionals have lost their professional authority.  Everybody has lost the trust and confidence of everybody else.  We live in a society in which people trust each other less and in which people trust institutions less and which people trust callings less.

I don't actually think that professions are particularly weakened in their ability to assert their authority as professionals.

The next suggestion is that professions are becoming businesses, and as I said before lunch,it's not so clear to me that there is actually any change.  I think it's very easy to perceive change because there is always an element of business and always an element of profession in any profession, and you look with dismay on the business side of it and forget that in the past that business side existed.

Now, the third possible thing that we may mean by the corruption of the market is that professionals are led to misbehave in some sort of way, and I take it that that is the purpose of the accountant example that Dr. Sullivan used.  And there are certainly misbehaving professionals. 

I remember just before I went to law school the problem with misbehaving professionals was Watergate.

The question then is what is the solution we're supposed to look to if professionals are misbehaving or otherwise being corrupted by the market, and this is where we have heard the invocation of the term "professionalism," a term that seems to me to have so many meanings that we can all love it, each in his or her different way.

I want to suggest that there are a lot of components that this professionalism might have, and here I'm just drawing on the article's apparent meaning in defining implicitly what professionalism might mean.

It might mean technical competence.  It might mean law abidingness.  It might mean obeying ethical rules.  It might be a concern with the just distribution of services, which we have a monopoly over.  It might mean participation as a citizen from the point of view of your profession.  It may mean sacrificing your client or your patient to some understanding of a broader public interest, or it may mean all of these things or some combination of these things or some combinations of these things plus some other things.

Dr. Relman correctly said this morning that any problem with professions is likely to be solved by a combination of three kinds of regulation:  self-regulation, government regulation, and market regulation.  None of these works very well.  Certainly none of them works across the board.

All of them have their virtues and all of them are present in the regulation of almost any profession I can think of.  There are a few exceptions.

We cannot avoid the market, as I think we agreed this morning, unless we return to the true meaning of an  honorarium, which was the amount of money that your client chooses to give you should your client choose to give you anything.

In the days before we had investors from the stock market investing in health care, we had doctors who were the investors in health care.  They were the ones who invested in themselves, who invested in their business and ran their business in order to get returns on their investments, and that produces its own kind of pathology.

And, indeed, we got to the managed care market because the fee for service market was seen to be injuring patients and society.

We are, in other words, driven to markets and to government regulation because the regulation of professions by professions has so often failed, almost necessarily fails because there is always a strong element of self-interest in the regulation of a profession when it's regulating itself.

Professions chronically and as nearly as I can tell universally, with one possible exception, do not discipline their own members with any kind of adequacy, do not get rid of the people who are incompetent and unethical with anything like the care that they should.

Professions speaking through their professional organizations regularly narrowly advance the interests of their own members, and Dr. Relman said earlier today that this may be doctors' last chance to really decide how their profession is to be regulated.  I believe they have already had their last chance.

Their last chance came probably decades ago.  I can  remember when I when I was a boy, since that is one of our topics of conversation, when the AMA made it clear that anything that moved toward socialized medicine was going to be opposed by doctors as vigorously as possible, and anything like any kind of insurance turned out to be a movement toward socialized medicine.

I think that when we think about why it is that government regulates professions, law and medicine particularly, more thoroughly through anti-trust laws, it is because the way that the professions behaved was not just regulating themselves in order to protect clients and patients.  It was using their ability of power over their members in order to keep prices up, in order to prevent groups of relatively poor people from forming groups to hire doctors on salary.

The case that people referred to this morning was a case in which lawyers were fixing the price of a very simple legal service across the board in that part of Virginia.

So I think that we have to face the fact that there are going to be regulations of professions in all of these kinds of ways, and the question then becomes what kind of balance do we have amongst these three kinds of regulations.

Now, the last question I think we have to ask is once we've decided on what kind of a solution to the problems of professions we want to adopt, we've got to decide how to implement that solution, and the modal answer to that question is education.  The modal answer to most questions in American life is education.

I am very touched and pleased at the confidence you all have in people who educate professionals.  I think it is a tiny bit exaggerated.  Let me try to suggest some of the reasons why you ought not to have so much confidence that I can fix things.

First of all, a lot of the problems with professions come because of external factors.  The market has been blamed for a lot of things.  In my instruction of my law students and my medical students and my undergraduates, I can't do anything about that.

Now, it might well be it's certainly more plausible to think that if the problem that we're really talking about here is a problem of professional misbehavior, of the Enron, Arthur Andersen, Watergate kind, that I ought to be able to do something about that by changing the attitudes that my students have.

But then I want to ask a couple of questions.  First, why is it that professionals do things that seem to us to be misbehavior?

Well, one of the reasons is because professionals being chronically in complicated moral situations often have to make choices in which they sacrifice some virtue.  In the accountant's and lawyer's situation and sometimes in the doctor's situation, you have to make a choice about whether to serve the moral duties you have taken on to your client or your patient or to turn you client or your patient into the law, and that is never going to be an easy kind of choice to make.

But that leads me to my second kind of problem.  One of the reasons that professionals misbehave is because people perceive the world in ways that are distorted by their own situation.  There is a very interesting and helpful article by a fellow named Bazerman called "Why Good Accountants Do Bad Audits," and he says that nobody who knows accountants thinks that the accounting profession is rife with crooks.  He says that the real problem is that if you are an accountant, you are very vulnerable to bias of an unconscious kind.  He says because of the often subjective nature of accounting and the tight relationships between accounting firms and their clients, even the most honest and meticulous of auditors can unintentionally distort the numbers in ways that mask a company's true financial status.

Even seemingly egregious accounting scandals, like Arthur Andersen's audits of Enron, may have at their core a series of unconsciously biased judgments rather than a deliberate program of criminality.

The third reason that professionals misbehave, I think, is because people respond to their situations more than they do to their own characters.  That is, I take it, one of the lessons of the famous studies that Stanley Milgram did, that people are much more motivated by the situation in which they find themselves and its incentives than they are by some character that they have.

Now, if those are some of the important, not all obviously, sources of professional misbehavior, it's worth noticing that these are sources that education can't do anything about.

Furthermore, the influence of education is limited in some important kinds of ways.  If you think that character is what is really important, you should realize that by the time I get them they're 25 years old, and their characters are probably shaped in very significant ways that I can't do a lot with.

Furthermore, however much I preach, however much I try to suggest to my students some of the important kinds of moral issues that will be at stake in their work, these will be abstract ideas that will very quickly be wiped away once the actual experience of practice starts, and I know of no evidence that the kind of professional education that we're talking about fixed professional misbehavior in either law or medicine, even though there have been serious efforts to make that kind of education work in both law and medicine for as much of history as I can personally remember.

I think that there is one way in which I might be able as a member of a law school to change people's behavior as incipient members of the profession, and that is by punishment.  When students cheat on exams, when students behave in seriously unethical ways, we could throw them out of law school and prevent them from becoming members of the profession, partly to eliminate people who will not be good members of the profession and party pour encourager les autres.  This is the last thing that an American law school is going to do.  It's the last thing that an American medical school is going to do.  It's the last thing that a profession wants to do with its own members.

So what I think would be the most important influence is the one least likely to be exercised.

I have to say that the calls for a broader kind of education, an education in liberal arts, an education that tries to get students to think about social justice in the broader moral aspects of their callings is a fine thing.  It's the way I try to teach, but if you think that that will make professionals the kind of people you want to see, then you should believe that we have now the kind of professionals that you want because that is exactly the kind of education that at least elite American law schools have been practicing at least 40 years.

The people who are lawyers now, the people who worked for Enron are the products of a system that educates people in the way that you're calling for.

That brings me back to professional autonomy and its failures.  Professions cannot reasonably be asked fully to regulate themselves, and that is why I think we need to think about what kind of balance of the three kinds of regulations you actually need in the specific context of each profession.

So I close as I started by saying I think we need to think with more exactness, concreteness, and more in terms of context about this problem than we have.

CHAIRMAN PELLEGRINO:  Thank you very much, Carl.

Would you like to respond, Professor Sullivan?

DR. SULLIVAN:  Very briefly because of the considerations of time.  Thank you very much for the very thoughtful response.

Just two points, I think.  The first is that I certainly don't want to imply that I'm opposed to a mix of regulatory strategy.  My purpose really was to defend the importance of professional revitalization, as it were. 

To put my cards on the table, the kind of problem which I was trying to suggest is more akin, I think, to the way in which we routinely think about other societies when we see them.  The classic case is always the description of old regime France where people say, "Well, it was just so venal and corrupt that they couldn't quite manage a reform."

And my fundamental belief is that the very nature of professional work is such that if there isn't, and I'm glad that we agree on this, that if there isn't a fair amount of this kind of sense within the profession, then really external regulation alone cannot do it.

So I was really only speaking of the professional part of that effort.  I mean, I think that that's a crucial and necessary one, and I think the second point I want to make is that I am not trying to make the claim that professional education sets people on a course for life which is going to be undeviating and uninfluenced by later development, but there is considerable empirical evidence that it's not so simple to imagine that students, as you said, arrive fully formed; that the best available evidence now is that that's really not so.

I mean, we know more and more about when people develop their (we would call it) moral conscience, and this even seems to be related to neurophysiological development, and it's interesting that the crucial moment for that actually is somewhere between 18 and 23, 24, where most societies have placed crucial things like ephebic training in ancient Athens and so forth, just at that point at which many people enter professional school.

So I wouldn't be so quick to dismiss that, and I think that if I was clear at all about the general view that I'm taking, you could begin to see what I meant about the way in which accounting, for example, could have gone wrong because of various influences that no one was perhaps individually to blame in a larger collective sense.

But there was a problem about not having the leadership or the conception of what they were doing that could have raised crucial flags, and I think the story that Paul Starr told 20 years ago about medicine has been borne out, that medicine's inability if not unwillingness, to really assume collective responsibility resulted in being regulated from outside.

DR. SULLIVAN:  I want to say thank you.

CHAIRMAN PELLEGRINO:  Thank you very much.

Are you responding, Carl?  I couldn't hear.

PROF. SCHNEIDER:  Oh, no.  I was just making a joke.

CHAIRMAN PELLEGRINO:  Okay.  I want to open it up to discussion now for the rest of the members of the Council.

Dr. Meilaender I saw first.

PROF. MEILAENDER:This picks up from a little different angle on Carl's request for specificity.  It's a little different angle, but there's a kind of a puzzle I have listening to your view, and one might put the puzzle simply by saying who is not a professional on your account. 

A professional presumably has something to profess, but it sounds as if what professionals profess on your account is just an ethic of  public service or something like that.

Almost everybody, I mean, you know, serving the public is not incompatible with making a living by doing it and so forth.  So you know, who claims to be interested solely in his own well-being?

The classical professions profess something much more specific than public service, you know, the good of health, the good of justice, the good of salvation, and so forth.

So that it just seems to me that if we're going to think about the professions today and whatever deformations they may have suffered, we need some more precise discussion of them than just the question of are they or are they not public spirited in order to kind of get at something.  It just seems too general to me in a way, but maybe I'm missing something.

DR. SULLIVAN:  That's a fair comment.  I was trying in a limited time to encompass a fair amount of territory.

In fact, you're right that these things have to be worked out within specific fields, but I do think that it's the case that the development of what we call the professions and which are recognized even in law in many cases as professions, in American history really does bear out the importance of this notion of public service.  It's public service precisely in responsibility for certain professions of purpose.

So I try to give illustrations about health and so forth.  So much so, I think, that to underscore a point I tried to make earlier, that it has been the organized health profession's apparent failure to, as it were, take leadership precisely around those issues that has annoyed the public in many cases; that it seems that the AMA, to take  a favor whipping boy of many people, which has actually lost membership in terms of the proportion of the profession who are now members, has simply been not a voice to talk about the larger functions of health in our society over the last 15 years, crucial years for the development of the situation of medicine in today's health care world.

CHAIRMAN PELLEGRINO:  Gil.

PROF. MEILAENDER:If I may just briefly follow it up, I'm still not sure I see where this takes us.  You know, I don't do sociological studies of what people think, but I don't much care if my doctor makes more money than I do as long as my health gets taken care of, and I think there are rather a lot of people like that; that the problem they discern, they'll be concerned if something goes wrong with their health care, not with some general question about whether the profession of medicine is enriching itself.

So that it's a more specific focus on the quality of care than it is on, you know, being service oriented versus self-interest oriented.  I don't think that's what worries people.

CHAIRMAN PELLEGRINO:  Rebecca.

PROF. DRESSER:  This is not your specific expertise, but it seems to me one of the worries in medicine today is about how industry, pharmaceutical companies and so forth through funding and other economic rewards to physicians and scientists have become part of the education and research missions of biomedicine.

It seems, based on my limited knowledge, to be a different kind of problem at a different scale at least than we've had in the past, but I'm not sure.  So I'd be interested in hearing comments about that.

But when industry inculcates itself into the training of professionals as well as how professionals carry out their work in research or medicine, is that something of special concern?

DR. SULLIVAN:  I think we have an expert witness.

CHAIRMAN PELLEGRINO:  We'll have to wait until tomorrow afternoon.

DR. SULLIVAN:  I can say one thing.  At the Carnegie Foundation my role really is to work with a variety of studies that the foundation has been doing on professional education, including the law and medicine, and that example is very striking.  Simply visiting a modern medical school, or for that matter a residency program, one of the most striking things to me was how much of the students and residents' lives were dominated, well, not dominated but let's say were accompanied by lunches and pizzas and all kinds of things provided, very clearly provided by what sometimes is referred to as "Big Pharma," and this is simply a part of the background of contemporary life, which suggests that at least to those corporations, professional education is very important for beginning to instill what they hope will be habits of connecting certain features of professional identity with their products over a lifetime.

CHAIRMAN PELLEGRINO:  If there are no other questions from the Council, Dr. Relman, I'll break a rule here if you'll be very, very brief.  The rule is that people who are not on the Council don't usually comment on the speaker, but I think because of this morning —

DR. RELMAN:  I don't want to violate your rule.  The question is: is it a problem that the pharmaceutical industry influences medical education at the graduate and postgraduate level?

I believe it's a terrible problem.  More than half of the cost of educating physicians in practice, so-called continuing medical education, now comes from the pharmaceutical industry.   Because of legal concerns about conflicts of interest and kickbacks, the pharmaceutical industry has been forced to separate its support of continuing medical education from the medical profession.

So in response to that need and in response to the opportunities for profit in health care, a whole new industry has arisen, one of the many new industries that has arisen around medical care.  They're called medical education companies, and there are dozens of them now.  They're sprouting all over, and their clients, their customers are the pharmaceutical industry.  They take money from the pharmaceutical industry. 

Company A says to Medical Education Company, "We would like to see you develop a program in the treatment of high blood pressure."  They happen to be manufacturers of pills to control high blood pressure.  "And so we'll give you the money, and we won't tell you what to do.  We won't tell what you should tell the doctors because that would be probably illegal now or unethical, but you understand," and the medical education company understands, "that if as a result of the money that we've invested in you in setting up that program, we don't see any effect on the sales of our product, we're not going to come back to you again."

So there's a very lively trade now.  I know a lot about this because I've devoted a fair amount of time watching it and seeing it.  There is clear evidence that this changes the behavior of doctors.  It changes the prescribing behavior of doctors, and it's a clear encroachment of the pharmaceutical industry on what should be the responsibility of the medical schools and the teaching hospitals.

I think it's a big problem.  I think it ought not to be allowed.  I've told the dean of my medical school that they shouldn't have anything to do with the pharmaceutical industry in this respect.  I've written about it.

The answer is money talks, and, "Dr. Relman, if we, the teaching hospitals and the medical schools and from the medical education companies and indirectly from the pharmaceuticals, who is going to pay for continuing medical education?"

That's the problem.  So thank you very much.

CHAIRMAN PELLEGRINO:  Thank you, Bud.

You had a comment?

DR. SULLIVAN:  No, thank you.  That was very well said.

CHAIRMAN PELLEGRINO:  Are there further questions?

(No response.)

CHAIRMAN PELLEGRINO:  If not, I think we will take a break for the next ten minutes because we have a program coming up and try to get back to our schedule.

(Whereupon, the foregoing matter went off the record at 2:37 p.m. and went back on the record at 2:51 p.m.)

SESSION 3: HEALTHCARE— WHO IS RESPONSIBLE? THE INDIVIDUAL? SOCIETY? BOTH?

CHAIRMAN PELLEGRINO:  We are back on the program.  Thank you very much, Council members.  Very good.

This afternoon, the last session is on the question of health care continuing, who is responsible, the individual or society?  That question has come up a couple of times already this morning.

We have three very eminent speakers, so I — take your time, Allen.  Since you are first, don't take too much time.  Our first speaker is Allen Buchanan, Professor of Philosophy at Duke University.  

And, again, remind those who have come in late, or later, we do not give long, lengthy introductions, because it's all in the record.  And so I'm delighted to welcome the three of these gentlemen who are all really prominent in the field.

Allen will start us off, and what we will do is have each speaker make his presentation, and then we'll open up to discussion all three, to the Council members.  So make your notes, if you wish, or your questions, so that at the end you can direct it to the person you wish.

Allen?

DR. BUCHANAN:  Thank you.  I am really honored to be here.  I was the principal staff author of the President's Commission in 1983 report "Securing Access to Health Care," and I have worked on issues of access to health care most of my career.  So I am intensely interested in the topic of this session.

And I want to commend you for resisting the temptation to jump right into the fray about current health care reform proposals.  And for your courage in being willing to grapple with the deepest issues, step back and take a deep breath rather than just comment on what's on the table.

In the spirit of your commitment to digging deeper, I'm going to try to begin by being provocative, by providing very short answers to the two questions I was given for today's session.  The first question is:  how are we to understand health care?  As a commodity?  A legal right?  A moral right?  Or a human good?  And the second question is:  is there a division of responsibility, say between the individual and society, for health care?

My answer to the first question is yes, all of the above.  My answer to the second question is no, but there ought to be.  That is, there ought to be a division of responsibility.

Now, with respect to the first question, in one sense the question, is health care a commodity, understood literally as a descriptive indicative statement is a no-brainer.  Health care clearly is a commodity in the sense that it's bought and sold in this country and elsewhere.

Saying that health care is not a commodity is a way of making a moral claim without making explicit that you're making a moral claim.  A bigger problem with the statement that health care is not a commodity is that it's not clear which of several distinct moral claims is being covertly made.

It could be any of these.  Is it the claim that health care should never be bought and sold?  Dr. Relman seemed to suggest that we should somehow insulate health care from market forces entirely, so that might be one interpretation of the claim health care is not a commodity.  Or does it mean whether one gets adequate health care shouldn't depend on whether one can pay for it?  Or does it mean even when health care is bought and sold, it shouldn't be treated as a mere commodity?

Those are all compatible with health care is not a commodity.  But is health care a human good?  Well, answer, yes, some of it is and some of it isn't.  Some health care kills you.  On some estimates, about 100,000 people a year in the United States die as a result of medical mistakes.  So presumably that health care at least wasn't good for them.

I'll try to compress a little bit in the name of time.

Let me just say one more thing about this claim that health care is not a commodity.  One hears a similar claim in the debate about intellectual property in genomics.  Some people say you can't patent life.  Well, in one sense, you can patent life.  It has been patented.  The real question is whether one should patent various items, and, if so, what the intellectual property role should be.

And, generally, I think it's better just to cut directly to the normative issues and not give ourselves false comfort by making statements that appear to be descriptive statements in the indicative mode, but are really ambiguous moral statements, moral claims, that need arguments.

Now, here is another reason not to begin your deliberations with the question of whether health care is a human good.  Doing so may encourage a mistake, not on your part but on the part of some members of the public, the mistake of assuming that health care rather than health is the basic concern.

For a long time we've known that not just health care but also public health, nutrition, and the absence of violence are important contributors to health.  And in the past two decades or so, we've learned that there are more subtle social determinants of health than clean water, sanitation, absence of violence, including, on some accounts, where one stands in an egalitarian social order.

That is, social inequality itself may have costs in terms of health status independently of the association of ordinary risk factors with lower socioeconomic status.  Focusing immediately on health care rather than on health misses this point.  Some studies, including the famous Whitehall study in England, suggest that social inequality may contribute to differences in health care, even where access to health care is more or less equal. 

Remember our initial question, one of them was, is health care a legal right?  Well, in the United States, there is a legal right to health care.  It's quite a limited right.  But the question that we should really be asking is:  ought there to be a legal right or legal entitlement for all citizens to an adequate level or decent minimum of health care?

And here is why in trying to think about that question one should not start out with the question:  is there a moral right to an adequate level or decent minimum of care?  Why shouldn't one start out asking whether there is a moral right?  Because doing so gives short shrift to other moral considerations than those having to do with moral rights.

And it also diverts attention from the fact that there are non-moral — for example, prudential reasons — for having a universal legal entitlement to health care. 

So it's a mistake to assume that there is a good case for having a legal entitlement to health care only if there is a moral right to health care.  Furthermore, if you mistakenly think that there ought to be a legal entitlement to health care only if there is a corresponding moral right to health care, then you may draw overly pessimistic conclusions from what I take to be the current unsatisfactory state of theories of the right to health care and of justice generally, to which I will now turn.

The bottom line is that those theories provide limited illumination.  Here I will be mainly just emphasizing a couple of points I made in one of the papers in your packet, "The Right to a Decent Minimum of Health Care."  The bad news is that even the most developed theories of the right to health care, including Norman Daniels' theory, are both morally controversial and, more importantly, too abstract to yield much guidance on the question of what sort of legal entitlement to health care we should have.

The good news is that theories of the right to health care and theories of justice generally appear to converge on the conclusion that there are good reasons, some having to do with rights, also some other reasons, to establish a legal entitlement for all citizens to some "adequate level or decent minimum of health care."

The reasons, as you might suspect, are mainly negative.  That is, there is considerable consensus that it's implausible to say that there should be a strongly egalitarian legal entitlement to health care understood in either of two ways — either as a right of each — to all health care that would be of any net benefit to him or her, or as a right of each individual to the highest level of health care that anyone in the same health care condition would be getting.

The problem with the first understanding of a strongly egalitarian health care entitlement is that it fails to acknowledge that resources are scarce and that health is not the only good in life, not to mention the fact that health care is not the only way of promoting health.

The problem with the second understanding of a strongly egalitarian health care entitlement is that it commits us to the highly counterintuitive conclusion that even if everyone is getting very high levels of high quality care at reasonable cost, or even no cost at all to themselves, no one should be allowed to use their disposable income to get any higher level of care.

So the idea of a legal entitlement to an adequate level or decent minimum of care rather than a strongly egalitarian legal entitlement is at least useful for making it clear that legal health care entitlement shouldn't be unlimited, and that people should be allowed some freedom to pursue health care above the legal entitlement, whatever it turns out to be.

Let me back up a minute, see if I can save some suspense.  Existing theories of the right to health care or, more generally, theories of justice, cannot tell us what the content of the decent minimum or adequate level of care is, though they can provide some minimal guidance, in particular some guidance on which sorts of health care are likely to be candidates for inclusion in this standard.

I don't think there is any reason to believe that there will be breakthroughs in theorizing about the right to health care or about distributive justice generally that will tell us how to fill out the content of the adequate level or decent minimum of care to which all ought to be legally entitled.

Instead, in the end, we'll have to rely on public institutional processes, primarily, though not exclusively, political and legal processes, to engage in the task of articulating, contesting, and revising operational understandings of the level of care to which all are to be legally entitled.  No amount of theorizing will do the trick, though the public institutional deliberations should be informed by the best theorizing available. 

Now I want to argue that there is one sense in which your decision to separate the how question of health care reform from the deeper moral and philosophical questions is ill advised.  I complimented you for it earlier.  Now I'm going to tell you why it's wrong.

It's ill advised, because it assumes that there is a neatly divided two-step process.  First, we get clear on the deeper philosophical and moral issues.  Then, we devise policies to implement the principles that we discovered in the first stage. 

I've already explained why I think this won't work.  We have no theories that can tell us what the content of a universal legal entitlement to health care ought to be, and it's unlikely that any will be developed in the foreseeable future.

But there is another more significant reason.  We cannot satisfactorily answer one of your deeper questions — who is responsible for health care — until we have two things. 

First, a politically effective social consensus that there should be a legal entitlement for all citizens to some adequate level or decent minimum of health care; and, second, a publicly credible, morally defensible, authoritative assignment of responsibilities for realizing the legal entitlement for all — an assignment of responsibilities for which various parties can justifiably and effectively be held accountable.

This is what we lack in the U.S. — we lack two prerequisites for answering the question:  who is responsible for health care?  Politically effective societal consensus that there ought to be a legal entitlement to an adequate level of care for all, and an authoritative assignment to determine the responsibilities for making the legal entitlement effective.

The crucial point is that we are not in a position where we're trying to discover what the proper allocation of responsibilities is.  We have to create the proper allocation of responsibilities.

There is no general answer to the question:  who is responsible for health care?  once we get beyond the banality that the responsibility must be shared.  Consider the more precise question:  who is responsible for ensuring that everyone has an effective legal entitlement to some level of care?  There is no general answer to that question either.

There are different ways of achieving access to health care.  In different systems there will be different responsibilities for various parties.  Substantive judgments of who is responsible can't be made out of thin air.  They have to be made against a particular institutional background.

Let me illustrate the point with an example which will probably drive Dr. Relman crazy.  In the 1980s, one often heard the allegation that for-profit hospitals were failing to provide care for indigent patients.  The facts were clear enough:  they were not providing much care for indigent patients.  But to say that this is a failure of the for-profit hospitals is to blame them, to assume that they're not fulfilling a responsibility of providing care to indigents.

Similarly, today one hears that managed care organizations are not providing to their enrollees some care that would be beneficial to them, with the suggestion that in doing this they're failing to discharge their responsibilities. 

But, of course, that would follow only if managed care organizations have a responsibility to provide their enrollees with all the care that would be of any benefit to them, but they have no such responsibility.  They have not assumed it, and no one has authoritatively assigned it to them.

The point is that the particular blaming judgments that I've mentioned about for-profit hospitals and managed care are not well supported.  Both judgments assume that the parties in question have some determinate responsibility without providing any basis for those assumptions.

They pretend, in effect, that we live in a society that has had the courage to face the problem of providing access to an adequate level of care for all, and has assigned determinant responsibilities for achieving those.  But that's not our society.

The result is what I call "duty dumping," self-serving and unproductive blaming.  If there is a societal obligation to make effective a legal entitlement to some adequate level of care for all, then pointing the finger at for-profit hospitals or managed care organizations, or even at the Federal Government, in the absence of an authoritative assignment of determinant responsibilities for access is simply bad faith.  It helps us to continue to evade our societal responsibility.

This kind of evasion also puts health care providers in an untenable position.  They're caught on the horns of a dilemma.  On the one hand, if they take literally the traditional medical professional's norm of doing the best they can for each patient, regardless of cost, they act irresponsibly by wilful ignoring the fact that resources are scarce and that health care is not the only good in life.  And they continue to contribute to the cost spiral that prompted the managed care revolution they so deplore.        It seems to me that often physicians talk about the managed care revolution on analogy with the popular film Independence Day.  One day they woke up and horizon to horizon was a huge alien spacecraft, came out of nowhere.  We hadn't done anything wrong, and it started sucking the life out of everybody.

I don't think that's really an apt analogy, because managed care didn't come uninvited.  It came at the behest of payers, government payers like Medicare and Medicaid, and employers who simply wouldn't put up with uncontrolled costs that the current system, dominated by the medical professional, was not controlling.

The analogy really would be more apt with Bram Stoker's interpretation of the Dracula story.  According to Bram Stoker, the vampire can't attack you unless he has been invited into your home.  And I think that's what happened with managed care.  Even if you think managed care is blood-sucking, it's not blood-sucking like in Independence Day, not by a long shot.

So one dilemma is — one horn of the dilemma is that if health care professionals stick to the traditional norm of doing the best they can for each patient as they come, as it were, one at a time, then they're denying the reality of spiraling costs, and they're just contributing to the problem.

On the other hand, if health care providers ration care but do so without being able to rely on some authoritative standard of adequate care to serve as a constraint on the withholding of beneficial care, then they can be accused of unprincipled rationing, of rationing that is dictated by concern for profit alone or is in some other way arbitrary.

So there's a great cost to not having a societal consensus on the commitment to establishing a legal entitlement to some level of care for all and making some progress on getting operationalized consensus on what that content is, a huge price, a huge moral price.  So that's just the point that I was making.

Now, in the second article in your packet that I contributed, I draw a distinction between two kinds of mixed private-public health care systems.  Type 1 systems are what might be called designed complementarity.  That is, there is a division of labor between government and private entities that makes effective a legal entitlement to some level of care for everybody.  That's one model.

The other model you might call the government gap filling model.  The government ensures that all get whatever the private sector doesn't provide, so that there is an effective legal entitlement to adequate care for all, and the government need not be a provider of care in any direct sense.  It may subsidize or finance care provided by others.

Now, in principle, either of these types of systems could be satisfactory, but the problem is in the United States we don't have either type of system.  Instead, we have a situation in which the government and some members of the public pretend that we have a Type 1 system, and then blame private actors for not fulfilling their assigned responsibilities, and in which private entities tend to assume that we have a Type 2 system and say that it's the government's fault if what the private parties don't provide fails to achieve adequate access to care for all.

But we don't, in fact, have a Type 2 system either.  We don't have a government gap filler system.  The government does not have a clear mandate to do whatever is necessary to bring everybody up to an effective legal entitlement to some standard of care if they don't reach it through the operation of the private market.

And why does the government not have that mandate?  Because what I said earlier is missing.  There isn't a clear societal commitment in this society to a legal entitlement for everybody to have something beyond access to emergency room care.

So my conclusion is that it's a mistake to start out asking, who is responsible for health care?  Asking that question at the outset plays into a delusion — the collective bad faith, whose pathology I've outlined.  It encourages the mistaken idea that the responsibilities in question are to be discovered when in fact they must be created.

So we cannot first answer the question:  who is responsible for health care? in any substantive way, and then go on to ask, what sort of health care system should we have?  Who has what determinate responsibilities will be system relative, though there are some general moral considerations that should guide the choice of a system, and, of course, one of them is among the options, which sort of system with which sort of assignment of responsibilities would be one which shelters and nurtures the right sort of professionalism, the kind of thing that Dr. Relman has been talking about.  And there are many other moral considerations.

Now, in the second article in the packet, Rationing Without Justice but Not Unjustly, I argue that we are in a peculiar situation.  We lack some of the necessary conditions for making determinate well-grounded judgments about responsibility for health care and also some of the necessary conditions for being able to make responsible, rationing decisions, and for making justified judgments about blame for who fails to ration properly.

So we first need to achieve a politically effective societal commitment to providing something like an adequate level of care for all.  Then, and only then, we can begin to tackle the task of developing an institutional division of labor with an authoritative assignment of determinant responsibilities for achieving an effective legal entitlement to adequate care for all.

Notice that the adequate level of care to which all are to have a legal entitlement, if that's the way we decide to go, cannot be fully specified in advance.  It will have to become better articulated as the process proceeds.

Now, let me just say one last thing about this seductive but elusive idea of an adequate level of care or decent minimum of care.  Remember I said it mainly plays a kind of negative role of saying that we don't want to opt for what I call the strongly egalitarian legal entitlement to health care, and, of course, by saying "an adequate level" or "a decent minimum" it also alludes to the idea that it should be something more robust and generous than the kind of legal entitlement to emergency care that we have now.

But beyond that, it doesn't tell us a lot.  And I don't think it can.  I don't think that idea itself, even when we combine it with the best theorizing about distributive justice or justice in health care can do the trick.  Instead, we've got to take the plunge and embark on the right kind of public deliberative processes to try to give content to the idea.  But, again, we can't begin that process unless we supply what we haven't had so far.

Let me say one last thing about the idea of an adequate level of care.  This idea was utilized, you know, years and years ago in the President's Commission report Security Access to Health Care, and I invite you to look back to that, because there are some things that are said about what the content should include and shouldn't include.  It's not by any means a specification.  Even back then we realized that you couldn't do that kind of thing a priori, that it had to be somehow worked out institutionally.

But at that time, there was something conspicuously absent from our deliberations about access to health care — that is, a global perspective.  We focused only on the question of whether there were arguments in terms of moral rights or other values for establishing some legal entitlement for all American citizens to an adequate level or decent minimum of health care.

But there was no awareness of the very disturbing problems of global health disparities, and not just the fact that we have better health status than many people in the world, but that many people in our world are suffering terribly and have horrible health conditions which could be remedied. 

People are dying of preventable diseases.  Life expectancy in the less developed world is very low.  People come into the world riddled with parasites, malnourished, all of that in addition to the HIV/AIDS epidemic.

Now, it seems to me that if you take a perspective that's even a little bit cosmopolitan — that is, you think that there are individuals out there who count morally speaking even if they are not Americans — a theoretical idea for some people, I doubt for anybody in this room — then, you've got to ask yourself in our process of trying to work out the idea of some adequate level or decent minimum of care to which all Americans ought to be legally entitled, should we be keeping in mind that as a society we may have some obligations with respect to access to care to other people beyond us? 

And if we do, then presumably those obligations will place some kind of constraint on how generously or robustly we fill out the adequate level of care that we are trying to establish a legal entitlement to for all Americans.  And I think that it is going to be very hard to do that, because I think there will continue to be advances in biomedicine which will raise our expectations for what counts as an adequate level of care for us as Americans.

And it may include things like retarding what we regard as the normal aging process, regenerative medicine, lots of other things, and so there is really a danger that unless we show some sense of constraint of the sort that Dan Callahan has talked about for many years that, you know, even if we get the idea that it should be an adequate level of care or a decent minimum of care for all citizens, it may inflate and inflate and inflate.  And that would have unfortunate consequences for lots of reasons, one of which is that it would completely rule out any sense of cosmopolitan moral concern.

Thank you.

(Applause.)

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Buchanan.

Our next speaker is Daniel Callahan, Director of International Programs at The Hastings Center and former President of The Hastings Center.

Dan?

DR. CALLAHAN:  Thank you, Ed.  It's a pleasure to be here, primarily because I know so many people, colleagues over the years, and it's nice to see them all together.

But just as much maybe I am pleased with this topic.  My own history in bioethics has pretty much followed, in many senses, a rather traditional trajectory.  One of our first projects at The Hastings Center, as Leon Kass remembers, on definition of death — we spent a lot of time on issues of definition of death, genetic counseling, human subject research, questions of who should live, who should die.  That was the kind of language of the time.

But as time went on, I became increasingly interested in the question of the goals of medicine.  What is this whole enterprise about?  Which I worked on in the mid-1990s, really '90 to '95, thereabouts, and then increasingly I became interested in the whole question of the organization of health care, thinking that there was a fundamental relationship between our notions of the appropriate goals of medicine and the way a health care system should be organized.

What I found, however, was a great deal of resistance in moving in this direction.  For many, bioethics essentially still means clinical ethics.  The notion that one in bioethics should take on health care is seen as moving into an area which is essentially politics rather than ethics.  As one indignant economist told me recently, because I've been working on the question of the market, "Well, that's not your field.  You're not an economist." 

And there are many people in bioethics also who still feel that somehow this is more politics than ethics.  I think it's just the opposite.  I happen to think that the organization of health care systems, reforming health care, is the most fundamental problem.  I think issues of stem cell research, cloning, all of these come back to the question:  what is it appropriate for medicine to be doing for people?  What are the fundamental goals of medicine? 

And, therefore, what is it proper in a health care system to begin distributing and trying to give to people?  Where should you draw the line?  How far should you go?  So that's why I'm pleased that this topic is here.  There aren't many of us in bioethics that work on it, because of a certain bias against it all, but I hope more and more will in the future.

So with that said, let me begin.  The United States is undergoing one of its periodic health care upheavals, and every other developed country is having trouble as well.  Whether you use the language of crisis or simply talk about the need for serious reform, there is general agreement that we cannot continue on the present course.  And many other developed countries have similar worries.

I mentioned the universality of the problem, because it would be a mistake to think that it is merely a matter of better organizing our jerryrigged system.  That managerial move is necessary, but the deeper problem is that no country has found a satisfactory way to manage the expensive and endless war against illness, disease, and death that is the modern medical enterprise.

It is perversely a war that seems to get more, not less, expensive with every victory, every extra year of life gained.  The healthier we get the more we spend.

Now, organizing health care systems encoded with that dynamic has turned out to be a daunting and frustrating matter, and exacerbated by the many unique conflicting interests that mark American health care.  But the problem is a common one.

For all these reasons, I believe the question has to be seen as a universal problem, one very much coming back to, what do we think health care is all about?  What are its fundamental purposes and goals?  What are its boundaries and its limits?

Now, I want to try to make all of this rather concrete by talking about two what I consider practical problems essentially and two foundational problems.  They overlap considerably, though.

I begin with the practical matters.  One of them is that of providing health care for the 46 million Americans who do not have it, either temporarily or long term — a number that steadily grows. 

The other practical problem is that of steadily rising health care costs, increasing at a rate of about 7 percent a year, a nasty kind of compound interest that will wreak havoc with the Medicare program in less than a decade, at least the trustees say that, and with the entire system roughly in the same timeframe.  It's expected within about a decade our health care spending will double.

I call these issues practical not because they lack ethical dimensions, but because they have particularly challenged the future viability of American health care, requiring an extraordinary degree of managerial and political savvy to deal with.  Those are my two practical issues — the two foundational issues, the ethical roots and medical markets.

One of the foundational issues is that of the ethical roots of health care systems.  Upon what understanding of human nature and ends should health care systems rest?  And upon what understanding of the quest for health and the ends of medicine as a part of that quest should they rest?

Those are questions that American politicians are wary of confronting, that are too deep, too complicated, and likely, many think, to drive people apart rather than to bring them together.  Nonetheless, I believe they are unavoidable.

My own approach is to start with the assumption, earlier uncontroversial but now more contentious, that we are finite creatures, born to live eventually — but to live but eventually to die, and whose life as a whole should be valued more for what is done with it than for how long it lasts.

The aim of medicine should be within a finite life span to help us have a good chance to go from being young to being old, to relieve us of our physical and mental disabilities if possible, to rehabilitate us as best we can if we are disabled, and to help us achieve as pain-free and peaceful a death as possible.

Medicine ought not to seek an indefinite extension of life, or aim to enhance our nature beyond the ordinary standards of good health, or to find medical means of relieving us of all pain and suffering, many of which are now and will always be unavoidable.

I further believe that an average life expectancy of 80 or so, which we are approaching in this country, is long enough to achieve most of the goods that life affords us if we are to achieve them at all.  A longer life may mean a better life for some, but those individual benefits are not likely to be community benefits.  We may not like death and finitude, but they are good for us as a species and good for us for the vitality of our community.

There is, of course, a connection between the two practical problems I began with and this fundamental problem.  If we are to have universal health care, to what should all of us be entitled?  How far and in what way should a health care system be prepared to go in our quest for health and avoidance of illness?  And if we are to control costs, to what extent and what way should cost be a consideration in patient care?  And what if that care is to save a life?

The other fundamental problem is that of the tension between the belief that health care is best provided by the government versus the belief that it is best provided by the private sector.  I call this the market problem.  This tension is obviously a part of the present debate over health care reform.

Now, to call this the tension might seem either too strong or too mild a term.  It is too strong if understood to be a black or white matter, just simply private or public.  All sides seem to agree that some government support is necessary and that some private sector care is desirable.  Getting the right balance is the real challenge.

But it can seem too mild in light of the passionate and conflicting ideologies that mark the debate, usually cast in the most moralistic language possible.  Consider the editorial pages of The Washington Post versus The Wall Street Journal or the Nation Magazine and that of the Weekly Standard.

I call this a foundational issue, because if one moves back from the inflamed rhetoric there is a basic clash of values, each with a long history.  That clash is between a communitarian understanding of our common life — man as a social animal going back to Aristotle, and man as a maximizer of self-interest, the more recent position notably advanced by Adam Smith.

Care must be taken here not to attribute cartoonish positions to them.  Aristotle surely understood the importance of the individual and of the need for virtuous individuals as the basis of a good society, just as Adam Smith understood the importance of empathy and of sustaining moral order as the basis of a good market society.  Even so, they represent different conceptions of the individual and the community and offer divergent foundations for health care.

Now, the appropriate starting point in thinking about the organization of health care is that of the foundational issues.  So let me say a little bit about them.  I favor universal health care because I see the preservation and pursuit of health as a necessity for the security and flourishing of society.  Societies can surely survive with a high level of poor health, and many do, but a healthy society is a better one.  I won't try to defend that proposition.  I think it can easily be defended.

Medical progress, together with a better understanding of public health and the role of background of social and economic initiatives have obviously made an enormous change in the perception of health and illness.  They have steadily brought — steadily been brought under human control. 

We live longer and healthier lives than any humans in history.  Nonetheless, we still live under the threat of sickness and death.  They remain an enduring part of the human condition, and there is no reason to think it will ever be otherwise.  This is true for each of us as an individual and each society as a community.

Since the threat is both individual and collective, a health care system needs to be organized with that truth as its moral basis.  For just that reason, I have been much drawn to the European idea of solidarity as the foundational concept for the provision of health care.  I take that term to mean that in facing our mortality we are all in it together.  We share a common thread of illness and death.  We, thus, need each other and are joined by our shared faith. 

Moreover, when health care is enormously expensive and getting more so all the time, then we face a common economic threat.  Unless we are very affluent or wealthy, we cannot, as individuals, pay for our own care or that of our families.  We need each other economically.

It has been common in bioethics for many years, in larger political liberal circles at least, to use the language of rights or of justice to make the case for universal care.  The language of rights has significantly faded, well symbolized, as Allen will remember, when the President's Commission decided to talk the language of obligation rather than rights.

For reasons I won't develop here, I have never been an enthusiast for the language of justice either.  I don't believe it is very illuminating except in some very narrow sense of fairness with an agreed-upon entitlement program.  And it certainly has not worked as a motivational concept, much too theoretical and abstract to move the public.  And it has none of the powers, say, of empathy, which was of course one of Adam Smith's great contributions.

I press the notion of solidarity not because I rate its chance of acceptance as strong in American culture, but because the rights and justice approach has failed, and there can be at least no harm in trying a different route.  Most important is it has served wonderfully in Europe and Canada to provide a sustained impetus for universal care. 

The ideology-driven phrase that characterizes universal care as "socialized medicine" is blithely ignorant of its European history, which goes back to the social teachings of Pope Leo XIII in the late 19th century, and to the German Chancellor Otto von Bismark during the same period.

It was the latter who put in place the first universal health care system, and he did so as a way of thwarting rather than embracing socialism.  The fact that every European government, right or left, since then gradually came to adopt that policy at the least should suggest that there is nothing inherently socialistic about it at all.

Solidarity is, first and foremost, a moral concept, a way of characterizing mutual obligations we should impose on ourselves for our common good, and that is the spirit of the European systems.  In this country, we understand that national defense at the national level and the provision of police and fire protection at the local level are necessary for our collective welfare.

But not even The Wall Street Journal or The Weekly Standard refers to these government services as socialistic.  We don't talk about a socialistic Department of Defense.  Why, one must ask Americans, is not our need for health care as important as our need for national defense, fire, and police protection?  Public opinion for 80 years now has favored universal care by a large majority, so the public at least gets the point.

Now, while an increasing number of social conservatives have now seem convinced that some kind of universal health care system is needed, the main argument centers on the comparative role of market ideas and practices within such a system.  Market advocates wanted to have a strong, even dominant role, and they have behind them, of course, the present administration.

If solidarity is the central value for universal health care, choice and competition are the central value for political conservatives.  In one sense, this emphasis can be seen as quintessentially a reflection of American individualism and its focus on choice and a reflection of American business life and its focus on competition.  Each individual should be free to choose his own kind of health care, and he should be able to select among a goodly range of commercial providers for its provision.

But in another sense, this emphasis no less reflects the history of an animus against government.  It can be traced back as far as Thomas Jefferson, and more recently to the influence of Friedrich von Hayek and Milton Friedman.

Moreover, one does not have to be a market enthusiast to appreciate the extent to which European health cares have worked in recent decades to bring many market practices, particularly competition, into their universal health care systems.  They do so, however, to improve and complement those systems, not to compete with them.

Markets, I readily grant, can have a useful, if subordinate, role in building a good health care system.  What moral weight should — ought we to give the choice in competition?  We can give them a light weight by recognizing that most people do like to have a choice of doctors and hospitals, some say in the way they are treated and are willing enough to have their care paid for by competing insurers.

But many market advocates, at least in my reading, give choice and competition a heavier weight.  The classic difficulty with giving a heavier weight is that the market is not a neutral tool, just as the choice that is part of its armamentarium is not neutral either.  The market does indeed promote national prosperity, but it does so by eschewing any judgment on the  morality of the choices made.

The market will sell us whatever we will buy and believes that it is not part of the market's job to decide what we ought to buy or how we ought to morally live our lives.  The use of the market, then, while it has many practical advantages commercially speaking, makes it a dangerous solvent of traditions in moral values — a point well acknowledged long ago when Irving Kristol wrote a book with the title "Giving Competition Only Two Cheers, not Three."

The profession of health to a society, relying on the art and science of medicine as its primary vehicle, should be as medicine itself — should be an altruistic enterprise seeking the health of its citizens.  To put at the heart of that enterprise a set of values that is aimed simply to bless free choice, not the goals of medicine, and that makes individual choice a central commitment, not the good of the community, is a dangerous move.

Adam Smith believed in an invisible hand, one that could transmute the self-interest and motivation of individuals into a collective benefit.  That may be true in many spheres of our civic and commercial life, but it is still to be demonstrated as true within health care.

But the real danger of choice in competition as basic values is that those choices in American medicine are heavily dictated by the commercial health care sector — selling everything from insurance to drugs and devices.  Their motive is not health — though that can be good for profit — but the making of money for shareholders.  American medicine is unique among the nations of the world for its thorough going commercialization.

Health care industries have among the highest profit of all industries and aggressively sell their profit, now allowing directed consumer advertising which only one other country — New Zealand — allows.  If socialized medicine is a bad idea, the high cost of invariably poor health comes to match those costs, make what can be called commercialized medicine a far worse idea.

Here I pay tribute to the life-long work of Arnold Relman for going after that kind of medicine, often corrupting the system and distorting the values and traditions of medicine.  I want to spontaneously remind people there was a story in the newspaper yesterday that the average psychiatrist in the State of Vermont receives $45,000 from the medical industry, mainly by selling drugs for children, prescribing and selling drugs for children.  $45,000 is an incredible figure, I think.

Anyway, let me return, then, to the practical problems — universal care.  I have not heard anyone over the years who has upheld a large number of medically uninsured citizens is a good thing for American society.  If nothing else, one way or another the public pays for the lack of care and for the economic and social burdens that their increased risk of illness and disease carries with it.

The 15,000 deaths a year that the Institute of Medicine has estimated as one of the prices we pay for that omission is not a trivial figure.  Moreover, as a nation, we can clearly afford to pay for universal care.  Why, then, do we not have it, particularly when public opinion polls have for so long found the public overwhelmingly in favor of it?

One obvious answer is also found in those polls.  There is considerable disagreement about what form universal care should take.  It ranges from a continuum of government versus market-oriented schemes, and there has always been some disagreement coming out of those polls about how much people would be willing to pay to have it.

Another reason is the sheer number of conflicting economic and professional interests, most with the stake in keeping the system as it is, one that is profitable for doctors and industry.

The reason I want to focus on here, however, is the deep-seated American hostility to government and the resistance at even looking carefully at the European health care systems.  By just about every possible standard, those systems are superior to ours.        They have bigger life expectancy, lower mortality rates for infants, higher quality of services that have gained considerable popularity with the service, and insurance coverage for everyone, and they do all of that for considerably less money than we spend.

According to some major World Health Organization and OEC studies, the U.S. ranks only 17th or 18th in overall comparison of health care quality in outcome in developed countries.

Three mistakes are commonly made by Americans in their assessment of European health care systems.  One of them is I think they are simply not worth looking at at all.  They are government-run or managed, and, thus, ruled out a priori.

The second is they constantly harp on the failure of two of these countries — Canada and the U.K. — as a generic indictment of them all.  The third, related to the second, is the failure to recognize that there are two types of universal health care systems in Europe, the so-called Beveridge system which is tax-based and government-run, and the Bismark social health insurance systems, which are financed by mandated employer and employee contributions and served by at least quasi-private insurance companies.

The first point to make is that the Canadian and U.K. tax systems are among the weakest of all systems, ranking down there near the U.S., which is pretty low on international surveys.  It is those countries that have the notorious waiting list, not to mention the serious shortage of doctors and nurses.  But those feelings are almost unique to the tax-based countries.

The social health insurance systems have either no waiting list or minor ones only, and all of them — tax-based or social service — have better health outcomes and lower costs than ours.  The social health insurance systems, which, say, include The Netherlands, France, and Switzerland, should particularly attract American attention.  They offer some useful models for the U.S.

Among other things, they offer a wide choice of physician and other health services, competition among insurers, coverage for all sectors of health care including drugs and long-term care.  Their lower costs are facilitated, of course, by strong government regulation — regulation that typically encompasses the introduction and diffusion of new technologies, negotiation to set physician fees and hospital budgets, and cost controls on drug prices — ideas that are not exactly popular in the U.S.

Yet they have been willing to experiment with many forms of provider competition and to introduce managed competition following the lead of Alain Enthoven, and to respond well to public demands for more consumer-directed health care.  But they do all of this, including the regulatory imposition, in the service of sustaining universality itself undergirded by — I'm sorry, sustaining universality undergirded by a commitment to solidarity.

While most of the American health care reform proposals now available are hybrids of one kind or another, a mixture of public and private provisions — few of those that rely on the private sector make any mention of government control of that sector.  The European experience should in that respect teach the U.S. one important lesson.  If costs are to be effectively controlled, the private sector cannot be allowed to run free.

The U.S. experience with an unregulated private sector shows that it does not and cannot control costs, and neither consumer choice nor provider competition is likely to make that make more than a marginal difference.

Since I became interested in the relationship of medicine and the market well over a decade ago, I have been a vigilant reader of The Wall Street Journal, Forbes, and other magazines of similar disposition.  Its editorial pages revel in knocking Canadian waiting lists, tending the glories of cheaper TV screens, assaulting socialized medicine, and glowingly describing the wonderful efficiencies and lower costs that the private sector can bring to health care.

The best antidote to that kind of rhapsodizing are the news stories in The Wall Street Journal about the private sector whose capacity for inefficiency, endless foul-ups, and unethical behavior certainly competes well with the very worst of government behavior.

Finally, I end with medical technology.  To my mind, it most vexingly joins together a practical and foundational issue.  As a practical matter, the control of technology cost is no less important than covering the uninsured. 

A seven percent annual cost increase is already wreaking havoc with their present system, and must be brought under control, and by "control" I mean an annual cost increase that is no greater than the annual cost of living increase which would put us in the two to three percent range of acceptable cost increase.

Health care economists, in a rare moment of consensus, have determined that close to 50 percent of that increase comes from either new technologies or the intensified use of old ones.  Any serious effort to control costs must then focus on the development and use of medical technology.

If a hearty dislike of government is one of the obstacles to reform in the universal care direction, the American infatuation with medical progress and technological innovation is one of the main obstacles to controlling and using — to controlling its use and cost.

Where the management of technology joins the foundational problem comes at what I call the frontier of medical progress.  That frontier always moving is that point at which the present moment displays the success of past technological innovations in saving life and relieving suffering, and the promise that future innovations will do the same.

We conquered polio and small pox.  Now we have moved on to cancer, heart disease, and Alzheimer's.  The notion that we might stop with those earlier victories, which cruelly killed millions, and not try to bring a comparable benefit to those dying of present uncured diseases and also killing millions, is for most people simply a cruel and unthinkable idea.

If it was right to bring the beneficial innovations of earlier generations, is it no less right to bring it to present and future generations?

Now, it is hard to oppose that argument, particularly if one has experienced the suffering and death of one of those many diseases not cured or controlled.  My response is this:  if cost control is necessary for the good of the health care system, and if the control of technology cost is critical in doing so, then it must be done.  There will always be a frontier of medical progress and technological innovation.  If everyone lived to 150 or 200, it would still be there.

What's good for us at present and what we need to live satisfactory lives is not to win that endless war against illness and death — a war that cannot, given our nature, be won.  We now need to learn how to live within the present frontiers of progress, moving ahead, if at all, slowly and carefully.

This we have refused to do in the past, but that must change.  If that seems a painful prescription for the health of the health care system, there is a consoling thought.  Those of us in developed countries now live the longest and healthiest lives in human history, and we know that what most determines the nation's health status is not medical care but the condition of life — jobs, education, income, and environment.

I could go on and say more about the need for prevention and shifting in that direction, but the point is we cannot continue simply throwing more and more high technology at medicine and expect to run a sustainable affordable health care system.

Thank you.

             (Applause.)

CHAIRMAN PELLEGRINO:  Thank you very much, Dan.

Our next speaker is Ezekiel Emanuel, Chair of the Department of Clinical Bioethics at the National Institutes of Health. 

Zeke?

DR. EMANUEL:  Thank you.  As the last speaker on a long and intellectually intensive day, I guess I don't have an enviable spot.  So I hope to be sufficiently provocative to keep you awake.

The first thing is, as Dr. Pellegrino mentioned, I am a government employee.  I can assure you that my comments don't reflect this government and the official policies of the Department of Health and Human Services.  No one has read my comments in that department.  They are simply my ideas.

The second disclaimer I need to offer is that I originally misunderstood my charge.  I understood that we were going to talk about individual responsibility for health — things like the West Virginia Medicaid situation — and had thought about that in the context of rationing and how much the individual dessert ought to play a role, and so I had prepared remarks on that, but more carefully read when I got the notebook what exactly I was supposed to do and how responsibility was being thought of in a different way.

So disclaimer three is a little skepticism, actually, about the topic being offered and whether this issue of who has responsibility, the individual society or both, is really the right question to ask, and I guess in this I am following Allen Buchanan's statement or his view.

And, in part, I guess I'm skeptical about this question because I don't think that's the real issue, and I don't think that moral thinking or moral resolution to that question is going to have much impact either on the moral thinking or, more importantly, on the actual change in the American health care system.

I think it really is an economic and political question that we're confronting, and that needs to be addressed to get a better health care system in this country.  And why do I think that, and why do I think, despite being a bioethicist and committed to thinking about the allocation of health care resources, don't I think we ought to think more about the moral side to it?  

And that is because I think we really do have a consensus that there is an obligation on the part of society to provide people with a — what Allen has called "a decent minimum," with some basic standard medical benefit package, and the issue is how and how big that package should be.  And that's really an economic and political question that ethics can add into.

But I don't think the question of responsibility is really unresolved anymore.  I think we do think society has that obligation.  When you have a Republican Governor of California, a Republican Governor of Massachusetts, very conservative individuals saying that — joining the Democrats on that, I just don't think we really have that much moral disagreement anymore.  There may be some, but I don't think it's big.

So why are we talking about responsibility in this way?  I would suggest that it's a combination of two factors.  The first factor is we have effective medical interventions that really do cure people of diseases, increase the length of life, improve the quality of life.

We should remember that I think in 1900 the average life span of an American was 47 years.  While a big increase has been because of public health measures, better housing, better food, we know that in the last 40 years at least half of the improvement in our life span has been because of medical interventions, and maybe a lot more. 

If we didn't have these effective medical interventions, we wouldn't be having this discussion.  Who cares?  There wouldn't be a discussion of who is responsible for giving people health care if we don't have any effective health care to give them.  So one is the ever-increasing effective treatments actually puts pressure on us to get them, because once they're effective people feel like they should be able to get them and that they're entitled to them.

And it is, of course, no historical accident that universal health care coverage and insurance began to develop in the late 19th and early 20th century just when we really began to have truly effective coverage.            It might also — it's an interesting note in American history, which I have had the privilege of looking at recently, that the first bill, as far as I can tell, where the United States Government provided health care coverage and services for the entire population was small pox vaccination.            After the proof of Jenner, and then Waterhouse, that it worked and that it really cured people, Congress quickly set up an office for vaccine — to provide vaccine — a cowpox vaccine to whoever in America wanted it and, as I understand, free of charge.

And the person to occupy that role was to have people around the country to whom he could send vaccine for people to get vaccinated.  So when we had effective treatments, the response of the country is actually for government to jump in and provide it. 

This is not a new debate in the 21st century — very early in the 19th century.  I think that bill, if I'm not mistaken, was something like 1807.  Very early in this country we have seen that if you have an effective intervention people ought to be entitled to it.

So one reason we're having this debate about individual responsibility is the fact that we do have effective treatments that people want.  A second reason is, as everyone has responded, high cost.  After all, if these treatments were pennies a day, like vaccines, we wouldn't be talking about that either, because government could afford it, we could pay, and there wouldn't be an issue. 

That's why we do — the government does provide vaccines for children as well as mandate that they use them.  It is only because we have high costs, which we are perceiving to be intolerable or unsustainable or pick out any phrase that seems to capture that that we're talking about it.

Everyone is trying to shift the responsibility for paying this to someone else.  Business is shifting it to individuals.  Government is looking to unload it onto individuals.  This obviously does link back to the West Virginia Medicaid case, and the language in Massachusetts of individual mandates, trying to shift the responsibility onto someone else to pay for that.

So it's this combination of effective treatments and high costs that are getting us to think about it, and I think we're really talking about individual or social responsibility, who has it, because everyone is trying to shove it off on someone else.  But I think to be honest, the real issue here is who pays.

Now, the conventional wisdom out there, if you follow the debates and certainly the Presidential candidates' various proposals, the proposal in Massachusetts is it's a shared responsibility.  I think Dan used that term.  It's a shared responsibility, a little employer, a little government, a little individual.  I think that's all hogwash.

We, as individuals, bear the responsibility.  If you look at it fiscally, we absolutely bear the responsibility.  When employers provide health coverage, who really pays?  Any economist will tell you it's the individual who pays.  It's just part of compensation.  People are basically giving up wages for a benefit.  If the employer stops paying, wages go up and should go up. 

If government took over, most employers would increase their wages to compensate people because of the competition for skilled labor.  It is, in fact, individuals who pay.  The conduit may be employers, but that doesn't mean that individuals aren't paying.

And, similarly, last I looked there is something called the Medicare tax.  We pay it, individuals pay that tax.  Medicaid — it comes out of the general fund.  I don't think this is really — you know, when you look at it fiscally, you boil it down, you uncover all the economics, the fact is individuals pay those taxes, they pay the premiums, they pay it in compensation.

Maybe the question is, really, should it be voluntary on individuals, or should it be compulsory on individuals that this question is really getting at?  And I think that's a very important question.  How much should it be?  People can decide whether they want it or not, and we would let them live with that choice, including bleeding in front of the hospital door, and how much compulsion should there be so that everyone has to have something.

I take it that we're not going to be — allow people to voluntarily decide whether they want or not want.  I take it that the requirement that doctors and hospitals provide emergency care means that we are not going to let people bleed outside hospital doors if they haven't bought insurance, and that does seem to me to mean that we do recognize a social responsibility to guarantee some coverage.

As I said at the start, I think that's actually a settled question.  I don't think it's a particularly interesting question that we're going to disagree very much with.  There may be some libertarians in the room who will take a different view, but I don't think there's much sympathy for that position in American society.

Let me shift to think about what I do take beyond the "who pays?" question is the other very important question, which is the real question, which is:  how much are we obliged to give people?  And here on both Allen Buchanan's conclusions I am in much agreement and sympathy.

This is the way I think about it.  It's a slightly different take, but I think I come down very much in the same place as Allen Buchanan.  If we gave people a fair allocation of resources, then we might expect individuals to pay for health care and buy their own health coverage, and we might have good markets in which they could do it, although I'll come back to why I don't think actually the markets will work from a practical standpoint that feeds back.

The issue is, then, what's a fair allocation to people that, then, would allow them to buy the care they wanted?  And the problem is that we can't determine what a fair allocation of resources is to people without knowing how much health care should be covered and how much health care should be part of that fair allocation.

And it seems to me that's the sort of endless circle we're in when we think about this problem.  We know that we should cover something between zero — and I've suggested for all sorts of reasons it's above zero — and something short of every available intervention that is effective.  As Allen says, we haven't gotten much progress of where in between that is.

Now, Allen is skeptical about the fact that ethics and thinking about it from a moral standpoint is going to get us much progress.  I am not so skeptical.  I think we have actually had quite little thinking about this in a systematic fashion. 

I think we have grasped on to a few principles, like equality of opportunity and not really thought through much more — much more deeply the fact that no single principle is going to work here.  We're going to need a complex integration of principles.  I do think that there can be a lot gained by looking at how much we're willing to trade off economically for benefits.  I don't think we've had that much deep thinking about this for a whole variety of reasons.

Nonetheless, I do think, secondly, there is agreement between Allen and myself, and I think this is, again, pretty uncontroversial.  There is some minimum that society ought to cover.  I think it's — if we put it up, it's going to be pretty robust.  I will suggest that it's not everything, but it's something like the Federal Employees Health Benefit Program.

And I think that it won't cover everything, and people, given our views about liberty, should be able to buy above that.  I think that's a major ethical question.  I think that's also a pretty settled ethical question.

There should be a guarantee of a minimum, but above that people should be able to buy more services, even more effective services, that other people won't afford.  And I don't think that there is — as I said, I think that there is a lot of social agreement about that.

Let me end these very brief comments with why I think, for a variety of reasons, you  might want some elements of the market, but you cannot have a voluntary system and have it work in any structural, prudent way.  I don't think believers in the market in health care have really thought through what the market in health care would look like and where particular market failures occur.

We know from Ken Arrow's work, now almost 50 years old, that market failure is a serious problem in health care because of information asymmetries, and that is a very, very fundamental problem.  But I think that almost all other aspects of having non-compulsory markets lead to problems and failure. 

And let me give you one example, which I hope is a way of urging the thinking about the fact that funding for the minimum has to be compulsory and universal, in part to ensure that the structure of the whole health care system is going to work.

Almost everyone agrees, whether they're left, right, in the center, or far out in some other field, that we're going to have to have insurance exchanges that make insurance companies or private health plans compete on a standard benefits package and allow people to go in and buy from them based upon competition or on service and quality, maybe some added benefits, the range of doctors covered, the range of hospitals covered. 

You see this in Massachusetts with their "Connector."  You've seen this proposed in almost every health plan reform except for some far-out single-payer plans.   Conservatives like this, liberals of a certain stripe like this.

If you think through these insurance exchanges, having them in a voluntary basis, i.e. society doesn't guarantee it for everyone, doesn't force everyone into them, they are guaranteed to fail on purely economic grounds.  We've seen it over and over again.  Every business — every time we have set up an exchange on a voluntary basis, whether it's in California or Minnesota or many other places, they fail.

And you heard it here first — Massachusetts' Connector will fail.  And the whole system there is going to go up in flames because of it.  Why is that?  Well, in health care, who would go into an exchange to buy insurance if it were voluntary?  Anyone who is sick who can get a better price in the exchange than they can get outside.  Who will not go into an exchange?  Anyone who is well or thinks they are well and can get a better price outside than inside the exchange.

If you make it voluntary, that kind of choice is going to happen, and it leads to a very predictable cycle.  Prices go up, because the healthy people have stayed out.  The sick people buy in.  Costs go up, because if they are sick, they're getting more care, premiums go up.

Even less healthy people who were originally in go out, and only the sick remain, and the whole thing collapses.  It has done it every single time.

What does this mean?  And you can play this scenario out in almost every single other aspect of health care.  You can have market aspects of health care where individuals take responsibility, delve into the market, and do it. 

But you can only have those aspects once society has mandated and that there is compulsion to participate and compulsion to get other factors, other elements, necessary for health care delivery — good information so people can actually know what they're choosing, create incentives so that people are actually competing not on profits but on quality of care.

So I would submit to you the following three conclusions or four conclusions.  First, I do think we've come to a societal agreement that there is social responsibility to provide a decent minimum, and I think our challenge now is to figure out what that decent minimum is and the political and economics that make it viable.  I don't think another moral argument is going to make a hill of beans worth of difference, to be perfectly blunt about it.

Second, I think ultimately the system is going to have to be, to that level, compulsory.  People are going to have to participate, because I don't think we can do it any other way.  But above the decent minimum, it seems to me that people are entitled, as a matter of justice, to buy more, spend more, to do whatever they want with their money, including buy whatever health care services, effective or ineffective, that they want.

I am not sure figuring out — that we can figure out at the moment more than this, and exactly how much services society is obliged to pay us.  I do think that at the moment is a political question, and I think we're going to find out the answer to that in the next few years.

I do think that ethics can help there.  I think more thinking will help there, but probably not in the lifetime of this next four or five years.

Thank you.

(Applause.)

CHAIRMAN PELLEGRINO:  Thank you very much, Zeke.

I think we will have a few questions from the Council, and then take a brief break, and then return for a continuation of the discussion.  Dr. Robby George will lead that.

Any questions now for the immediate — for the three speakers?

DR. FOSTER:  Yes, I want to ask a question.

CHAIRMAN PELLEGRINO:  You can direct it to anyone you wish.

DR. FOSTER:  I know that you — the thrust has been you can't decide what minimal care is going to be.

CHAIRMAN PELLEGRINO:  Go ahead, Dan.

DR. FOSTER:  Can you hear?  Would anyone want to throw out just in broad terms, not held to anything, what you think minimal care should be?  The issue that I'm concerned about is that minimal care that lets you go into a doctor's office if you're sick, but precludes other things, oftentimes uncovers a catastrophic illness.

And, for example, this week a young woman comes in with a urinary tract infection, looks like she's got a little blood in her urine, she thinks she has a urinary tract infection and she's got a bladder cancer — sorry, an appendicial cancer that has invaded the bladder.

The ordinary costs are pretty easy to handle.  I mean, one of the problems is that we don't have catastrophic insurance, and I wonder if there is — if there is some system that you might think that ordinarily would pay a couple hundred dollars or something, but was protected from the catastrophic illness.  You've got widespread cancer, you've got all sorts of things of that issue.  Does anybody want to just thrust a general question about what minimal coverage should be, or might be?

DR. EMANUEL:  Let me just make three points to that.  First, I think actually — I thought your example was the leading argument against the health savings accounts and catastrophic insurance, because that is exactly — that behavior, you come in only — you forestall all services, and then you come in only when it's a disaster is exactly what that catastrophic insurance behavior would encourage.

As a matter of fact, it's a — for all sorts of economic reasons, we know that people will not spend small amounts of money for preventive care when they see no benefit, when they are feeling no pain, and will put things off until they're catastrophic.  So as a matter of fact, I think your example was the best example I've heard in a long while of why health savings accounts are a disaster.

Second, it seems to me it does point to many things that we would think should be basic and should be covered because they're effective, and yet the system doesn't do that — that you would want to include in a basic benefit package.  You would want to have no cost for prevention that you know works — control of hypertension, control of cholesterol, vaccines, etcetera, screening tests that actually work as opposed to being hyped that they work.

You would actually want maybe even to pay people to get those things, so that they would actually do it.  It would be cost savings to you.

But my own view is, you know, we could talk — I actually like the Federal Employees Health Benefit.  I'm a beneficiary of it.  That's what I get.  I think it does a pretty darn good job.  It doesn't cover everything.  And you know what?  If you figure out how much it would cost to cover everyone in the country with it, we would actually save money, and it's a pretty good package, you know, if — as I like to say, if my favorite Congressman can get it, then, you know, it seems to me most Americans would be happy with it.

DR. FOSTER:  I think you misunderstood.  I'm not talking about preventive medicine.  I think that's one of the biggest hypes in the world.  You know, we know how to prevent the most common disease in the world, which is diabetes.  Very simple.  You lose weight. 

You know, I have hundreds of patients that are curable right now without — I mean, if you try to deal in real life with preventive medicine, there are some people that are going to lose weight and watch their lipids, and so on, but I'm talking about somebody who has some sort of minimal care, that because they got sick came in. 

I don't know how you're interpreting this, but they got sick because they thought they had pneumonia or something like that and you — I'm concerned about the issue of limiting care for people who are on the minimal edge for catastrophic illness when and if and if it surely will develop.

DR. EMANUEL:  Well —

DR. FOSTER:  I just want to be sure that the definition of "minimal care" includes the possibility of — not taking cosmetic surgery or anything like that, but the possibility that a poor person can get cancer that is going to cost $100,000, I mean, even just doing routine things without these new drugs that save you a month that they will get care.  That's what — I don't want to define "minimal care" as something that's a dollar-based protection of the patient.

DR. EMANUEL:  Well, mostly it's going to be an insurance package.  And, again, like the Federal Employees Health Benefit, of course covers that kind of cancer care.  But let me say one other thing about — or two other things.

First, if you look at the increase in longevity that medical interventions have provided over the last 40 years, you look at those data, almost half — almost half of that increase has occurred from one intervention — lowering blood pressure and lowering blood pressure not by exercise but typically by cheapo beta blockers, diuretics. 

So that — I mean, I agree with you.  Most of preventive care is hype, but that's actually preventive care that has done huge amounts.  I mean, you know, you saw the mortality rates from stroke just drop five percent a year when those drugs were introduced, and heart disease and renal failure, etcetera.

So, you know, I do think that's important.  The second thing I would say is 70 to 80 percent of the health care spending in the system is accounted for by chronic illness.  Right?  You're going to have to cover chronic illness.  That's where the money is.  You're just going to have to do it better than we do it now.

CHAIRMAN PELLEGRINO:  I think I'm going to intervene at this moment and ask Dr. George if he would extend the discussion.  We haven't the time to do it the way we had planned to do.  So go ahead, Robby.

PROF. GEORGE:  Well, thank you, Dr. Pellegrino.  But are you saying, then, that we will not go with the break that you had talked about a moment ago?  Because I thought the plan was that I would go after the break.  Has that changed?

CHAIRMAN PELLEGRINO:  I was going to change it, but —

PROF. GEORGE:  Fine.  Yes, okay.

DR. FOSTER:  I move that we take a 10-minute break, and if we have to stay 10 minutes longer, we'll stay 10 minutes longer.  Okay?

CHAIRMAN PELLEGRINO:  You would like to have the break?

DR. FOSTER:  I would.

PROF. GEORGE:  I knew I could count on Dan wanting to put off hearing from me as long as possible.

(Laughter.)

(Whereupon, the proceedings in the foregoing matter went off the record at 4:14 p.m. and went back on the record at 4:33 p.m.)

CHAIRMAN PELLEGRINO:  We will return to the discussion.  We will return to the discussion.

Professor George, would you pick up at this point?

PROF. GEORGE:  Thank you, Dr. Pellegrino.

CHAIRMAN PELLEGRINO:  And my apologies for getting you off the rails.

PROF. GEORGE:  No apology needed.

I really should simply stand aside and let the six members of the Council who are physicians — a majority as it happens today — of the Council members present engage with our distinguished panelists and see if we can get some real disagreement going.

But I am grateful, Dr. Pellegrino, for the opportunity to make brief opening remarks to launch our discussion on the topic Health Care:  Who is Responsible?  The individual?  Society?  Both?

Before doing that, however, I want to take note of the fact that we are really privileged to have with us on the panel three of our nation's most gifted and respected thinkers and writers on questions of distributive justice pertaining to health care and health.

Many of the problems we face in this area may prove to be unsolvable, and we may indeed have to settle for the least bad alternative and agree to disagree amongst ourselves as to which alternative is least bad.  I hope that isn't the case, but any way one looks at it there are huge difficulties in this area and difficult choices.

If we are to approach these challenges at all in an intelligent manner we will need to draw on the reflection and analysis offered over many years by Drs. Buchanan, Callahan, and Emanuel, and those of their colleagues in the fields of ethics and political theory and public policy who share their moral seriousness and intellectual clear-headedness.

We've heard in the past, especially in our discussions of organ transplantation and the possibility of a market in organs,  strong libertarian voices, and of course it would be good to have the best of those on the libertarian or more market-oriented side in this debate as well.

But what we have heard this afternoon are important contributions to the debate and will, I'm sure, importantly inform our own reflection.  I recently had the honor of giving the 2007 John Dewey lecture in philosophy of law at Harvard.  The irony of my being the Dewey lecturer was evident to everyone concerned, including myself.  What is the world coming to?  Will we next have the Freiderich Nietzche lecture by Leon Kass at the University of Tubingen?

(Laughter.)

Or the Michel Foucault lecture delivered by Paul McHugh at the University of Paris?

(Laughter.)

I think I heard one of our speakers linking together Pope Leo XIII and Otto von Bismark.  I thought that was great.  Was that you, Dan?  Yes.  Well done.

So in the spirit of irony, I took the occasion at Harvard to explore and defend some ideas about natural law and natural rights.  I thought that might make Dewey turn particularly quickly in his grave.

Now, there are some people who, following Jeremy Bentham, reject the whole idea of natural rights or moral rights or human rights as — to use Bentham's famous phrase "nonsense on stilts."  But there are critics of natural rights who come at the problem from a decidedly anti-Benthamite perspective.  They oppose utilitarianism of any description, and believe profoundly in the dignity of the human person.

Yet they reject rights talk as implying or even entailing a radical individualism which is incompatible with a proper understanding of human dignity.  They propose to tackle problems of justice, to be sure, but without resort to the concept or language of rights.

I argued in that lecture I gave that a proper understanding of human dignity and its demands excludes theories of either the radical individualist or a collectivist sort.  Neither of these approaches to understanding the human and common good can do justice to the concept of a human person; that is, a rational animal who is a locus of intrinsic value and, as such, and in himself who may never legitimately be relegated to the status of a mere means to others' ends, but whose well being intrinsically includes solidarity with others and membership in communities in which he or she has both rights and ordinarily responsibilities.

There are natural rights or what are today more commonly called human rights.  If there are principles of practical reason, moral principles directing us to act or refrain from acting in certain ways out of respect for the well being and dignity of persons whose legitimate interests may be affected, for good or for ill, by what we choose to do or what we refrain from doing.

I certainly believe that there are such principles, though there are of course many people who deny the possibility of such principles.  If I'm right, they cannot be overridden by considerations of utility.  At a very general level, they direct us in Kant's famous formulation to treat human beings always as ends and never as means only.

When we begin to specify this very general norm, we identify certain important negative duties such as the duty to refrain from, just to take an obvious and today uncontroversial example, enslaving people. 

Now, although we need not put the matter in terms of rights — I'll grant the critics of rights talk such as Joan Lockwood O'Donovan that much — it seems to me perfectly reasonable, and I think often helpful, to speak of, say, a right against being enslaved, and to speak of slavery as a violation of rights, of natural rights, of human rights.

Such a right is a right that people have, one that every community is morally obliged to protect by law, not by virtue of being members of a certain race or class or profession or sex or ethnic group, or what have you, but simply by virtue of one's humanity.  In that sense, it is not only a natural right but a human right.

But there are, of course, in addition to negative duties and their corresponding rights certain positive duties or obligations.  And these, too, are often — these days especially — articulated and discussed in the language of rights, though here it is I think especially important that we be clear about by whom and how a given right — putative right — is to be honored.

In my Dewey lecture, I used an example — as an example claims of the sort one hears all the time to a right to health care, the very subject of our discussion today, or a certain minimum level of health care.

Of course, as Dr. Buchanan points out in one of the articles he kindly provided for us, one sometimes even hears claims about a right to a certain minimum of good health.  While I agree with Dr. Buchanan that this last claim isn't at all plausible, I would say that it is not unreasonable to speak of a right to health care and a certain minimal level of it, although it is not obvious that this claim, as opposed to the alternative and weaker moral claim, that for example everyone ought to have access to a certain minimum level of health care or that it would be a good thing if they did.

I'm, here again, quoting Dr. Buchanan.  But having said that it is not unreasonable to speak of a natural right or a moral right or human right to health care, I would hasten to add that much more needs to be said if it is to be an interesting or even meaningful statement. 

Who is supposed to provide health care to whom?  On what terms?  Why should those persons or institutions be the providers or payers?  What place should the provision of health care occupy on the list of social and political priorities?  Is it better for health care to be provided or paid for by governments under socialized systems or by private providers in markets?

Is the existence of health care rights or the content of such rights affected by the health damaging or health jeopardizing lifestyle decisions of people who might claim such rights?  If so, how and why?  If not, why not?

Now, these questions certainly require moral reflection, all of them do.  But notice that many of them cannot be resolved, probably none of them can be completely resolved, purely by reference to moral principles.  They require technical — for example, economic — and very often prudential judgments including judgments of the sort that can vary depending on circumstances people face in a given society at a given point in time.

Often, in my judgment at least, there is not a single uniquely correct answer, the way there is a single uniquely correct answer to the question:  should people be enslaved?  Is there a right against slavery?  What should the government do about the question of slavery?  Should it permit choice in the matter of slavery, or not? 

Where I think there are uniquely correct answers, we're in a different area when it comes to positive — alleged putative positive rights, like the right to health care or a minimum decent level of health care.  Often there are choices as between options that though reasonable, or at least not unreasonable, offer — and I think we just have to face up to this — incommensurable costs and benefits, pros and cons, so that, you know, you probably never thought you'd hear this from me, there is a legitimate relatively of judgment in these matters that — I hear Paul giggling about this.  There's the notorious relativism of natural law thinkers.

The answer to each question, as you pursue them, can lead of course to further important questions, and the problems can be extremely complex, far more complex than the issue of slavery, where once a right has been identified, its universality, basic content, and the fundamental terms of its application are fairly clear.

Everybody has a right not to be enslaved, and everybody has an obligation, as a matter of strict justice, not to enslave others.  Governments have a moral obligation to respect and protect the right, and, correspondingly, to enforce the obligation.  When you're talking about that kind of a negative right, things are pretty straightforward.

Now, that doesn't mean you can't have a huge social upheaval and disagreement about them, even fight a civil war about them.  But they have a clarity that I think is simply not possible when we're talking about putative positive rights such as the right to health care, or, for that matter, education.

So as I say, things are not at all so clear with regard to these positive rights or claims of positive rights, even if we grant at least for the sake of argument that there is a right to health care or some minimum level of health care. 

So perhaps we could launch our discussion by thinking about whether, in fact, we believe that it's true that people in general, or at least people in a society such as ours with our level of affluence, our political structure, and so forth, have as a matter of moral fact a right to some level of health care, some minimum level of health care, and, if so, what follows from that for how we should think about health care policy questions and options.

Of course, Professor Buchanan, both in his presentation and in the excellent papers he provided for us, said quite a good deal about these issues.  Dan Callahan has written about them over the years, and said some important things about them today in his presentation.  And Dr. Emanuel addressed them, although less fully, in his remarks.

So we at least have some idea of where our panelists stand.  I wonder what we ourselves, as members of the Council, and particularly those of you who have been in the health care systems, on the front lines as physicians, think about these moral and prudential aspects of the problem.

Thank you.

CHAIRMAN PELLEGRINO:  Thank you, Robby.

Members of the Council, want to respond?  Dr. Carson?

DR. CARSON:  Well, a very, very interesting theoretical discussion this afternoon.  And certainly I think I would be amongst that large group of people who would agree if someone came up to me and said, "Do you think you should have health care?"  Yes, I would say yes, absolutely.

I think everybody would agree that that would be the case.  But when we're talking about having basic health care rights for people, I don't think we can really have that discussion without talking about how much it costs.  And I really haven't heard anything about that today.

It seems to me like it's going to be an enormous price tag associated with that.  So I would certainly like to hear some numbers thrown out with regard to that.

Also, is there in any of your minds room for perhaps some alternative methods of providing health care rather than this sort of universal rights issue?  And maybe there is some responsibility of individuals that should be considered here.

As an example, you know, the cost of health insurance is extraordinarily high in this country, probably more so than in most places.  No one has really reined the insurance companies in on this, or really questioned them deeply about why the costs are so high.  However, one thing we do know is that, you know, 39 cents on a health care dollar goes to pay administrative costs, more than twice what goes to pay professional fees.  Those are huge administrative costs.

What do you need for good health care?  You need a patient, and you need a health care provider.  Along came the middle man to facilitate the relationship.  Now the middle man has become the primary entity, and the patient and the health care providers are peripheral — there to support it.

So the question becomes:  are there ways that we can perhaps get those costs down to a reasonable level?  And by doing so, make insurance something that people can afford to buy?  And if they can then afford to buy it, there is where the government perhaps comes in and makes it mandatory, just like it's mandatory for you to have automobile insurance.

It can be done, I believe, by utilizing computers to do billing and collections, by removing catastrophic health care as a responsibility for the insurance companies, things like that which would drastically drop the cost. 

And if everybody owns their own health insurance, now we can say to them, "If you get an annual physical examination, you get a two percent discount."  That will incentivize people to get that insurance — to get that examination.  We begin to catch things early.  There is another whole level of savings there, but perhaps it will also force us to begin to think about wellness rather than sickness.  And I think there is where the real savings comes in.

I just don't want us to get lost and continue to spend all of our time talking about sickness and how to treat it and not deal with wellness, which is really where I think the right comes in.  We have a lot of medical knowledge, and it's not being disseminated appropriately.  We're talking about the raging epidemic of obesity that is going on in our country, particularly amongst youngsters, but, you know, we're saying, "Why don't you guys stop putting sugar into cereal?"  And we're not saying to young people, "Go out there and exercise."

You know, you cannot gain weight if your caloric input does not exceed your caloric output.  You know, we need to be talking about some basics in getting that knowledge out there about what health really is.

CHAIRMAN PELLEGRINO:  Someone want to comment?  Zeke?

DR. EMANUEL:  It's a broad-ranging consideration, but let me make several contexts — contextual points.  First, we spend $2 trillion a year on health care.  About $1.4 trillion of that is on personal health care services, so that's the bill you are — for all Americans, including those on Medicare.  That's the bill you're looking at.  That's what we're spending today.

Now, I guess to some degree I agree with you, we don't need to spend a penny more to cover the uninsured.  We do need a more efficient system.  I don't think your number of 39 cents on the dollar going to administrative costs is anywhere in the ballpark.  It couldn't possibly be in the ballpark, given what we're spending.

I would go back to a comment I made before the break, which is 70 to 80 percent of the dollars we spend are on chronic diseases, and that requires us, when we think about it, to think about chronic diseases and how much its individual responsibility — and also what it would take to actually provide good care for that.

Very little of the health care system is for your broken arm, your sutures, the accident that your kid happened to have, even for acute heart attacks.  I mean, it's for asthma, it's for congestive heart failure, it's for cancer, it's for COPD.  And the question is:  how do you deliver good care for that that is cost effective?  You know, I'll tell you one thing that has seemed to me to be critical. 

You need integrated health care delivery, and you can't have just a doctor working separate from a hospital, separate from a respiratory therapist, separate from the pharmacist, separate from the visiting nurse.  And the question is:  how do you create incentives in that direction?  I don't think that's a matter of individual responsibility, and I don't think saying more about individual responsibility is going to change much on those numbers.  From a big macro standpoint, I think individual responsibility is a sideshow, frankly.

CHAIRMAN PELLEGRINO:  Allen or Dan?  Dan?

DR. CALLAHAN:  Just a quick comment on obesity.  I have been struck by the fact that obesity really reflects an entire way of life rather than just individual behavior.  I live in a town where 90 percent, 95 percent of the kids are — ride to school on school buses even if you're as close as a quarter of a mile from the school.  There are no sidewalks.  And it's — and the food — and they have TV, they have computers, they do all sorts of sedentary stuff.

And to change all of that, you've got to change the whole social structure of a lot of our society to do that, and it's — and you can preach at people a long time, but it — things aren't organized to be thin.  That's, to me, the fundamental problem.

CHAIRMAN PELLEGRINO:  Allen, any thoughts?

DR. BUCHANAN:  Just sort of to reinforce what Zeke said, there may be a perception amongst some members of the public that arranging things so that everybody had effective access to some adequate level of care would be more costly than what we've got, but I think there is just no data to support that for the reasons that Zeke said.

And so perhaps one of the things that this body and other bodies that are in a position to influence public opinion could do would be to come up with some scenarios of alternative ways of achieving effective access to some adequate level of care for everyone, including what you were suggesting — that is, require — and what Zeke was suggesting, requiring everybody to have health care insurance, but then specifying some standard benefit packages so there could be price competition and quality competition for getting them, and play out some scenarios about what this would cost, and disabuse people of the idea that providing access to everybody — for everybody to adequate care is going to cost more than what we've got.  In fact, show them that it could cost considerably less.

CHAIRMAN PELLEGRINO:  Thank you.

DR. FOSTER:  I want to follow up on an earlier thing that Dr. Emanuel said.  He used the perfect example that, you know, hypertension and stroke has gone down because it is treated with drugs, usually three or four drugs as you had mentioned.  Heart disease has gone down because it is treated with drugs — aspirins and statins, and so forth.

I spent my life working on diabetes and obesity, and I guarantee you you will never solve the problem of obesity unless you get pharmacotherapy for it that stops the eating.  And so one of the things that we have to — I mean, I'd like to know — other than vaccinations, preventive medicine has had huge effects other than drug therapy, and so part of what has to be built into this is the capacity — and I think that what some minimal care would be — that you could get maybe — you might save money, a whole lot more, by preventing these things.

But I'm only confident in prevention of the common diseases if you have something that can be — is not a matter of personal will to do.  I mean, I don't know whether you all would —

DR. CALLAHAN:  In other words, you are really saying we should treat obesity as strictly a medical problem to be treated by medical means, even though we might agree the reasons why people are obese, it's not a medical cause.  It's because we have —

DR. FOSTER:  Well, it just depends, Dan — it just depends on whether you want to —  it's not just an American problem, it's a world problem.  The leading cause of liver disease now is fat in the liver which leads to cirrhosis and leads to cancer of the liver, and so forth.  It's all stuff with fat.

So, and all those people have to get tremendous care.  The metabolic syndrome can only be blocked by losing weight.  And if you can't lose weight on your own, which only five percent of people do — statistically, five percent, despite all the guidance, meeting with the dietician, and so forth, then, sure, I would think that it would be say a prudential reason — I mean, for saving money in the system by preventing that disease. 

Now, if they don't take the medicine, then that doesn't make any difference.  I mean, people say, "Well, why should you give them something if they can't control it themselves?"  They keep eating an ice — you know, a sundae every night.  Well, if you want to try to cut the costs eventually, I think you've got to do that.

DR. EMANUEL:  Well, I'm not sure that there's necessarily disagreement here, which is Dan saying the cause of the obesity epidemic is clearly multi-factorial, but it is an entire social structure, one that has deemphasized physical education, increased the amount of time people spend in front of the TV, which is very highly correlated with obesity, made stores carry foods that aren't necessarily nutritious but have high sugar contents.

And your argument is, well, but we're not going to rearrange society, so solving it is going to be a pharmaceutical intervention.  I mean, at least one of the things I take away from both of those comments is this idea that somehow making people responsible for their obesity and making individual responsibility seems untenable as an ethical claim. 

For one thing, it's untenable because we've created an entire social structure which encourages it, and to make individuals then fight against that kind of social pressure seems quite untenable, it seems to me.

Second of all, I do find it quite interesting how we end up picking out obesity as opposed to lots of other things that we might identify.  It does, as you know, have a very high socioeconomic correlation.  I have never noticed non-helmet-wearing California Governors riding motorcycles being picked out as a thing that should talk about individual responsibility heavily. 

It tends to be things which we like to — you know, people who aren't in the mainstream.  There is I think a heavy amount of moralizing in what we end up picking out and identifying.  Skiers also somehow tend never to be — talk about individual responsibility for their legs.

So I'm against the individual responsibility, and I think you have both given very good reasons why that's probably an untenable route to go down.

DR. FOSTER:  I just want to make one comment about the motorcycle riders.  It's helpful for transplantation organs, you know.  That's —

(Laughter.)

That's for sure.  The transplant surgeons always — you know, they say —

DR. EMANUEL:  How many organs are we going to get from the California Governor?

DR. FOSTER:  Well, we haven't got it from him, but they wear these T-shirts that say, "Ride without a helmet.  It's good for transplantation."  But the other good thing that is happening is that the — in terms of pharmacotherapy, I don't — I think you'll find a lot of people like myself who believe this is the only way that we're going to go, is that the drugs are getting cheaper.

One of the things is that statins have now become generic, so you can get simvastatin generically now.  I can tell you that — let me just make one other quick point.  There is a gene, which I'm not going to talk about, PCSK9, which sometimes is — which is present in a loss of function in African-Americans who are very vulnerable to heart disease.  And their cholesterols from birth are 28 percent lower than a normal control person just protects against this.

Now, we can lower cholesterol with statins, particularly if you give a combination, 60, 70 percent, and yet you don't save lives like a 28 percent.  So many of us are now starting preventive therapy at 20, 25, not with diabetes, because it's clear from this genetic thing that to be just 28 percent down on cholesterol, that you don't find heart attacks period.  They just don't have it.

And so I think this thought of preventive therapy is a tremendous gain for us, if the drugs are safe.

CHAIRMAN PELLEGRINO:  Other questions from the Council?  Dr. Carson?

DR. CARSON:  It's really more of a comment than a question, but — and it goes back to, you know, I'm a little discouraged when I hear so many people throwing out the idea of personal responsibility.  And maybe that's because I'm a neurosurgeon and I believe in the human brain. 

And I believe that we actually do have the ability to think and to gain information from the past and the present and to project it and that we're not just sort of like little animals, little gerbils, or little lemmings who run off the end of the cliff just because everybody else is running off the cliff.

And I think when we adopt attitudes like that we really are taking away from what we are as human beings.  Now, when I think, you know, in terms of health insurance, if everybody owned their own health insurance, there are some real possibilities here.

For instance, if they become a lion tamer, their rate goes up.  You know, if they're going to climb mountains, Mount Everest, on a regular basis, their rate goes up.  Why should everybody else have to be responsible for somebody who clearly is going to be pushing the button?  If they're going to be riding a motorcycle without a helmet, their rates go up.

And when you begin to do that, you begin to affect behavior.  It affects behavior in the way that people drive their cars.  If they know that every time they get a ticket their rates are going to go up, or they may actually end up in a more precarious situation than that, they are going to stop doing it.

And I think we have to recognize that human beings are actually pretty smart, and not just give up and say that they can't do things.

CHAIRMAN PELLEGRINO:  Allen, I think you had a comment.

DR. BUCHANAN:  I just wanted to make a comment.  I agree with everything you say, Dr. Carson.  I don't think that Zeke was saying — and I know that I wasn't saying it — and knowing Dan's work, I know he wasn't saying that there is no such thing as individual responsibility.  I think there are two things to keep in mind.  One is the question of whether we can be on good grounds in some particular case in making a judgment about somebody's failure of responsibility.

The other is whether we are good enough to craft social policies which try to assign responsibilities to people and then penalize them in certain ways.  And the history of public health as an enterprise, especially when it comes to trying to hold people responsible for their health outcomes, is replete with prejudice, policy proposals made on the basis of bad science, and a tendency to mistake aesthetic judgments and rather dubious moral judgments for judgments about health. 

And so I think just in terms of fallibility from the past record we need to be very, very cautious about devising social policies that hold people responsible, say, for their weight.  That's not to say that no one is blamable for their failure to control their weight.  That's just a different question.

But, historically, it has been quite a dangerous enterprise to try to use social policy to assign blame and either reward or punish on issues like weight or other risk behavior.

DR. CALLAHAN:  I would simply add also it has been part of the medical ethics tradition that physicians treat patients regardless of why they are there.  And I'm sure you would do neurosurgery on a motorcycle accident victim who had not been wearing a helmet.  You would say, "Well, he should have been wearing a helmet," but you'll do it anyway, right?  Isn't that — that seems to be a wonderful tradition.

DR. CARSON:  Well, I'm not saying that, but all I'm saying is that we don't necessarily have to hold that person responsible for being fat.  But if we say, "Your premium goes up because you weigh 400 pounds, sorry," they're going to start thinking about it.  That's what I'm saying.

CHAIRMAN PELLEGRINO:  I think I saw them in this order — Rebecca, Robby, and then Gil.

PROF. DRESSER:  A couple of questions for I guess any of you, although the first one is more pertinent to what Dan Callahan said.  In your article in the New Atlantis, which I thought was great, you make a very compelling case for why liberals and conservatives are enamored of progress and the search for better technology.

So given that, I mean, it's rather daunting to — and you have been talking about this very eloquently for many years.

DR. CALLAHAN:  Uselessly, Rebecca.

(Laughter.)

PROF. DRESSER:  I'm not saying that.  You have some converts, but it really almost seems to demand a culture change in this country where we are so in love with technology and progress.   So sort of the politics of this.

And then, a related question is, Allen Buchanan talks a lot about social consensus and how other countries have gotten there and have the system and they have some consensus over what benefits should be provided or a mechanism for deciding about that.  Why can't we, why haven't we, are there any ideas for trying to help us reach such a consensus?

DR. CALLAHAN:  Consensus at which level?  Say deciding what's a basic package of health care?  European countries basically a lot of them do it by bringing groups of physicians and government officials, and they sit down and they work it for — sometimes once a year a package, and then they come back and they keep changing the package, but at least they have a mechanism for doing so.  And it's a function of — it's partly a function of budget.

They have a budget limit, and we've got X amount of dollars we can spend on health care.  What kind of package can we afford to put together?  That works.

CHAIRMAN PELLEGRINO:  Robby?  Oh, excuse me.

PROF. GEORGE:  Are you going to respond to the technology thing?

DR. CALLAHAN:  Well, here is my analogy.  I like to say that during my lifetime I've seen three revolutions.  Whether you like them or not, there are three that are important — environmentalism, civil rights, and feminism — three things that changed very radically the way people thought about long-standing traditions. 

I think health care is the next candidate for a revolution, because we are going to find — we are going to treat health care like the — progress in health care is like the exploration of outer space.  No matter how far you go, you can still go further.  But least the people in the space business understand that you — money does count.  So you settle for a space show rather than trying to go farther, and you say, okay, it would be nice if we could go farther, but that's all there is.

And I would — that's what I want health insurance — that's my model, is how we deal with a limitless possibility.  Right now, we don't like to — we know it's limitless, but we love it so much we refuse to stop.  But at some point we've got to stop, because it's wrecking the whole damn system.  That's what I — mine is a very pragmatic — you'd better change it, or you're going to be in great trouble.

DR. EMANUEL:  Look, I think that assumes technology is all of one flavor, which is new is necessarily more expensive.  Now, we have at least two industries that have proven new can be cheaper and better.  And part of the problem is the current incentive structure for people who develop technologies is exactly that — new that is more expensive will be covered by insurance, and, therefore, there is no barrier or no market barrier for them to develop that.

So the question I think is not:  can we get rid of technology or will Americans stop investing in technology or science?  I think that is — I do think that is hopeless.  That is the definition of "Sisyphean."  This is the new continent, the new country, that people who embrace the new deal.  I just don't see us as giving up the new. 

So the question I think has to be not are we going to develop more expensive technology.  The question is:  how do we get ourselves to develop biomedical technologies that are new but cheaper or do things more efficiently?  As the computer industry and the telecom industry have shown, that's not impossible.

The problem is you've got to change the incentive structure, so that drug companies will know if they've got new, and it's very expensive, it will not be covered, and only a few people will buy it.  There isn't a market for it there.  Ergo, you've got to do new, which is of a different mode.

And, you know, that's all about incentive structures in the market, and I believe — I don't have the same pessimism Dan does.  I believe we can change those kinds of incentives.

DR. CALLAHAN:  I, for years, asked people at NIH, "Can't you invent some things that are much cheaper?"  And they said, "Nobody theoretically knows how to go out and invent cheaper."

CHAIRMAN PELLEGRINO:  Could I ask the panelists to —

PARTICIPANT:  Respond to questions.

(Laughter.)

CHAIRMAN PELLEGRINO:  — wait until the Council members have had a chance to ask their questions.  I hate to interfere that way, but that's — time is running, and Robby George, Gil Meilaender, and Leon Kass, and I would ask you to give your questions and do not respond until all the questions are out.

PROF. GEORGE:  I am tempted to say that my question was:  what were you guys going to say to each other? 

(Laughter.)

I was kind of enjoying that and interested in hearing where it was going.  But, really, I just wanted to intervene very briefly to ask Allen a quick point of clarification, just so I — I want to make sure we're on the same wavelength here, going back to the discussion you had with Ben about the role and wisdom of taking into account lifestyle choices in making policy decisions about health care.

In responding to Ben, you spoke in terms of penalties, punishments, and rewards.  But it — for people who do think that lifestyle decisions are relevant or can be made relevant to foreign policy here, my understanding is that they're not so much concerned about penalizing and rewarding but just deciding what's appropriate to pay for and at what level, in view of lifestyle decisions that people choose to make.

Now, there would be a different thing if it were a matter of punishing and rewarding or even, you know, trying to discourage behavior, but it seems to me that that's not actually what's going on here.  And if I'm wrong about what we're debating, I'd just like to be corrected on it.

DR. BUCHANAN:  That is really helpful.  I really wasn't addressing that at all.  I was —

PROF. GEORGE:  Oh, okay.

DR. BUCHANAN:  I was looking at the narrower question.  But I think that some of the issues that Dr. Carson raised are really crucial, and I wish we had time to spend more time on them.

All I was suggesting was that there are certain kinds of behaviors which we might like to encourage or discourage, reward or penalize, that we have to be especially careful about, just given the past history of bad policy and judgment. 

But also, I'd like to suggest that some behavior, like getting people to slow down to avoid a ticket which will raise their insurance rates, may be much more malleable to material incentives than others.  And as far as I know, there is no evidence that the sort of overweight behavior is responsive to financial cost in any thing like the way that speeding is.

And, in fact, when you think about it, this is not surprising.  People who are morbidly obese are already bearing enormous costs for their condition, right?  I mean, they are socially not as attractive, they know they're at greater health risk, their mobility is impaired, sometimes their employment opportunities are impaired. 

And this may be an indication that at least for some people there may be something like an addictive element, supported by social conditions, and to think that such a person is going to radically alter their behavior because you add a small monetary cost, or you add a small monetary inducement when in fact they're continuing to bear these enormous palpable costs of their condition, I just don't think it's supported by the data.

I have looked into this, and I don't think there is any data to support the idea that that kind of behavior is as elastic, is as responsive to social incentives as was being suggested.

PROF. GEORGE:  Does anyone know about what the impact on cigarette smoking is when taxation or other methods are used to increase substantially the cost of smoking? 

DR. BUCHANAN:  You can get reduction in smoking with very steep rates.  You know, there is the marginal — diminishing marginal reduction of risks have to be really high, but it does work to some extent.  But there is no evidence that this works with overeating, as far as I know.

DR. EMANUEL:  We've plateaued on that, pretty much plateaued at about 20 to 25 percent.  And it is not just us, it is almost all the countries that heavily tax cigarette smoking.  Bingo, it's at 20 to 25 percent.

PROF. MEILAENDER:  I'd just comment, sort of in support of Dan Foster's point before about a pill, that the reason speeding is more amenable has to do with cruise control actually.

(Laughter.)

That's what stops you from speeding.  But I have lots of questions, and I thought I'd just address one to each of you quickly, if I may.  For Professor Buchanan, I wonder if you could just say a word — obviously, you know, you could say lots of words, but about if we got some kind of agreement on whatever we called it — a decent minimum or something like that — whether that would really help stop the spiral of costs, or whether doctors would still — you know, the clinician encountering a patient would still experience the same pressures to do things whether or not they fell within the decent minimum, or whether, you know, you just turn away.  So that would be my question for you.

I'll just give all three.  For Dan, a more philosophical question, you started by telling us characteristically about how, you know, 80 years was about long enough and you're a finitude kind of man, and so forth.  That's one kind of view.

But near the end of your talk, you said, you know, if cost control is necessary, then it can and must be done.  That's a different kind of claim, that — I mean, it would be good to do all these things, but we can't afford them, and we must control them.           That's quite different from saying, you know, even if we could do them, and we could afford it, you ought to just take your three score and ten or maybe four score and consider it.  And I'd just like to know kind of which you really think.

And then, for Dr. Emanuel, you said with respect to markets that, you know, there are information asymmetries.  And I do agree with that, understand that.  I think maybe a little less though, and I'd just be curious — we have all sorts of patients, you know, going to websites, sharing information, rather ordinary folk actually doing this.

And now maybe they're getting things wrong, you know, I don't know, although sometimes I think they're not.  But I think that does have some effect on the information asymmetry argument, and I'd just be interested in hearing what you had to say about it.

DR. BUCHANAN:  Now I've forgotten your question, because I got so interested in —

(Laughter.)

— in the last question.  No, I don't think that just getting a societal consensus on making sure that everybody has access to an adequate level of care, even some consensus on what the content is, will solve the problem by itself of cost escalation.  And I think you're right, you still have to think about the behavior and the culture of physicians and what this has to do with the cost problem.

There are still going to have to be limits.  There is still going to have to be some way of working out limits that is compatible with the right sort of professionalism or doctors and other health care providers.  So I just think this is a — that it's a first step, not just — well, to go beyond a bare consensus that we need something more than emergency care for everybody, but to actually begin a concrete process.

And that's why I like Zeke's idea.  I mean, part of the burden of what I was trying to say in my presentation was that we can't solve the problem of deciding what the adequate minimum is completely in the abstract.  We've got to engage politically, and we've got to look at other mechanisms that have been used in other countries for developing some kind of provisional and then revisable consensus on what the adequate minimum is.

But the point is we haven't taken that next step yet.  And that's why I said at the beginning you can't solve these issues about who is responsible for health care and what people ought to have access to and then go on to say now let's devise a system to implement it.  It's in the process of trying to actually create a concrete system that you're going to focus people's attention and attract the right interest to solve those problems.

But getting consensus on an adequate minimum won't solve the cost problem by itself, but I think it can be part of a larger strategy into which the cost problem can become more tractable.

CHAIRMAN PELLEGRINO:  Dan?

DR. CALLAHAN:  Yes.  I don't see the two ideas being incompatible at all.  My way of thinking about this is that I do believe in finitude, but I do believe in noting also that if we — if you don't believe in finitude, you're going to find you can't afford to pay for infinity, and you better — you better cut down, whether you like finitude or not, buddy, you've got these health care costs which are going to create so much havoc you're going to be miserable.  So I see the two coming together.

I want to say if you make it to 80, you're doing fine.  Don't expect a lot of the health care system after that.  You will, as a human being, not be hurt, and you will sure be helping society if you accept that view.

CHAIRMAN PELLEGRINO:  Zeke?

DR. EMANUEL:  I still think that there is a substantial amount of asymmetry in the system.  Even though people go to websites, they still — there's lots of things they can't get information on, you can't collect information on, that we need I think actually a collective social mechanism to get information on.

You know, you have no idea how good your doctor is in any concrete way unless society actually went out there and systematically assessed how well he or she performs compared to other people, similarly for hospitals.

And let's say it — you know, we've just seen with the FDA, similarly for all sorts of drugs that are out there on the market.  We need lots of other pieces of information.  And I think, you know, that information asymmetry is — it might go away if we had a collective way of sorting it out and portraying it to the public, or at least be diminished, but I don't think it's going away permanently.  I mean, doctors are still going to have a lot more information.

And, you know, let's be honest.  Insurance companies are going to have a lot more information than you and I ever have in terms of those decisions.  So, I mean, for me the most important thing is you actually need a central body to collect the relevant information, and that we don't have.  I mean, what we have now is more than information asymmetry.  It is information vacuum in the system that prevents the markets from working.

CHAIRMAN PELLEGRINO:  Leon, I think you have the last word.

DR. KASS:  Thanks.  This is also I think a question for Dan, but other could chime in.  This is in the spirit in the way of Gil's question as well.  On the one hand, you think that part of our trouble is a kind of inflation of desire for longevity and for more and more and more through technology.  You say you've been singing this song uselessly, and it should now have occurred to you why it's useless.

(Laughter.)

Which is to say —

PARTICIPANT:  I know my time has come.

DR. KASS:  I don't think the time has come, and I don't think — I sing the same song, but the mind can say what it wants to the blood, but the blood likes to course.  And even if one's own blood doesn't like to course, one wants the blood of one's loved ones not to — not to be silent. 

And to the extent to which we improve access and give everybody a fuller chance at the golden eggs that the medical goose is laying and will lay with even greater polish, if all the promises come true, this desire for more isn't going to go away.

In fact, I suspect that it's the very successes that have gotten us to this point that make the residual mortal illnesses and impediments even more offensive to us.  So it seems to me you're caught in a kind of bind where on the one hand — on the one hand you want to say, look, we've got to in a way provide for the in uninsured, we've got to bring them into the picture, we've got to in a way make these benefits available to all.

The net effect is going to be that more and more people are going to want more and more of the new things that medicine is going to do for these matters.  And I don't see — I mean, you can say bankruptcy will, of course, force something, but I don't think that the kind of radical change in human desires is forthcoming.

And the revolutions of feminism, civil rights, and environmentalism are no precedent, because you're dealing in those cases — environmentalism is, you know, way closer — way closer.  But the other two things are to deal with perceived discrimination, which only bigots are for, whereas people who love life are practically the entire human species.

CHAIRMAN PELLEGRINO:  Dan?

DR. CALLAHAN:  Well, I guess my quick response is, first of all, one reason I'm in favor of universal health care is that it will — particularly the kind that will have a national budget, European style and a cap, will force us then to really decide what's comparably more or less important.

The European countries basically have a greater life expectancy or much less cost by virtue of any government regulation.  They provide less technology, and people don't get as much as they do here.  But they still — people don't feel that their desire for life is not being satisfied.  I think it's — we have a social sickness.  Ours is an excessive desire in this country, and we are unwilling to face up to it.

And, granted, it's a problem.  I've got a problem on my hands, because the culture is so — the culture doesn't want it.  But you are expressing a view of American culture, which is not necessarily the view of other countries who have to deal with the same problem.  And I think theirs is a better culture for doing so.

CHAIRMAN PELLEGRINO:  Thank you all.

Paul, brief?

DR. MCHUGH:  A couple of points.  I thought that eventually we did come around to a certain kind of agreement that we are evolving towards anyway, a system where there will be coverage for everyone for a certain minimum, that it will probably come out of some form of insurance with Dr. Carson that that insurance might be given in costs that have incentives, one way or the other. 

That is, the poor will be given support for their insurance, so it will be portable, and the more wealthy who can afford it — if they are doing things to maintain their health, will have things taken away from them, and it may cost less.  And your idea that — Zeke, that ultimately there is a kind of system that you can buy for — the things for yourself and thus produce a two-tier system.

I just want to come back to this idea that there is going to be some kind of revolution in this.  It seems to me that the health care system in America has been evolutionary and not revolutionary, and with some great advantages to that — that conferences like this turn up and we argue and try to find out things that we could solve just today and see if that won't allow us to live a little bit longer, and there are advantages.

I am very interested in what works elsewhere, of course, and what fails elsewhere.  I think most of the social experiments east of the English Channel have been a failure since 1789, so I'm —

(Laughter.)

— I'm quite sure that you can find plenty of things that are failures over there.  Most of the people in this room do — are here because somebody was wise enough to get in a boat and get out of it.

(Laughter.)

Come over here.

So I just wonder if, in the end result, we haven't really kind of agreed that we are going to work towards a two-tier system, given what we are, we're going to have insurance that works and we're going to have catastrophic insurance that presumably, in my opinion, with Dan will work with government support and will evolve and will continue to evolve, and we'll learn in that way how to be even better than we are today and make this point.

Is that correct?

(Laughter.)

PARTICIPANT:  I don't agree.

(Laughter.)

CHAIRMAN PELLEGRINO:  I think we'll call it a draw at this point.

(Laughter.)

Thank you for a very vigorous discussion, all of your — the Council and the panel members.  We thank all of you for being here.  We'll be here tomorrow afternoon.  No, we'll be here tomorrow morning at 8:30.

(Whereupon, at 5:27 p.m., the proceedings in the foregoing matter were concluded.)


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