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Thursday, November 8, 2007


Session 3: The Healing Professions/Medicine

Council Discussion

CHAIRMAN PELLEGRINO:  It's 2:00.  I'd like to ask the Council members to be seated.  Thank you.  Is Dr. Davis around?  He gives us our legitimacy, so we'd better wait.  Here we are.  Oh, good.  Thank you, Dan. 

This afternoon we continue the discussion on the question of the profession of medicine.  And we have a staff discussion paper, which I presume the Council members have read.  And the discussion will focus on that, and we'll start it with the members of the Council themselves, who will be the discussants, rather than having an outside discussion on this point.

I have Dr. Daniel Foster first.  Dan, is that all right that you kick off?  We appreciate it.

DR. FOSTER:  Okay.  I don't think I have anything profound to say, but I will say several things.  I read David Miller's paper, and I thought it was very well written.  It has much in there about issues that could occupy Council's discussion.  And I don't see anything wrong with publishing a paper like this.  It's a paper.  Most of the people in the field—I mean the doctors themselves and others—are not going to read a document like this.  They don't have time, and they're not interested, and the few people that are interested in "professionalism" will do that. 

But I thought it was very well written and brings in things like implicitly the eighty-hour education rule, which has resulted in a concept of noncontinual care of patients.  I mean, the residents work until 1:00, and then they leave, so you have this sort of interrupted care, and that's something that's important, but I'm not sure we're going to do anything about it, because the evidence is pretty overwhelming they're going to cut it from eighty hours a week to sixty hours a week, and how you teach medicine in sixty hours a week, I don't know.

Ed and I talked about this today.  I think the term "professionalism" is really not what we're talking about here.  What I talk about in this is true physicianhood—true physicianhood—not professionalism—true physicianhood.  And one of the problems we have with everything in medicine and science is trying to differentiate between what's importantly new and what is trivially new.  And I have sort of a visual metaphor that I'm going to ask you to imagine, because I don't have it here.

There is an African-American sculptor who made out of a single tree a ladder that is 36 feet tall.  I'll show you where you can look at its picture, because it was used by Joe Goldstein in his 2006 Lasker Award address when they were announcing the awards.  But I'm going to use it in a slightly different way.  So it has over a hundred steps in it.  So at the bottom it's two feet on a rung, and at the top it's an inch on the rung. 

And Joe was using this—and it was dedicated—it's called the Booker T. Washington Ladder.  Puryear wanted to say what Booker T. Washington had to overcome to achieve what he achieved, including an honorary degree from Harvard when he was forty years old and so forth and so on.  And Joe was using this ladder, which is not straight—I mean, it curves a little—a single tree—when he was talking about people who are gifted enough to win the Lasker Award and to reach to the top.  But I want to use the metaphor a little differently.

We publish—I don't know what the last year was, but let's say 550,000 papers in the biomedical literature in a year.  That's a little more than a paper a minute.  And so the question is how do you differentiate between what's importantly new and what's trivially new?  And the two-foot ladder is a sign of the trivially new. 

Now, I want to say something gently, and I don't want you to consider me as a Gazzaniga here, with some sort of a blunt statement of this.  But we've had several sessions on professionalism here, and I myself have not seen anything that I thought was importantly new.  There are variants.  But I haven't seen anything that grabbed me as importantly new.  They're all nuances of what goes on.  And the reason for that is that true physicianhood has been around for a long, long time and hasn't changed.  The environment in which it works has changed, but it has not changed.

Paul, I was at Johns Hopkins, and they had wanted me to talk in a grand rounds there.  I was invited both by the Department of Oncology and the Department of Internal Medicine.  They wanted me to talk about physicianhood, and I gave a grand rounds that was entitled "On Becoming a Physician—Unchanged Since Antiquity."  And when you go back through this long line of physicians over centuries, the message is the same.  It's called a noble profession.  And then there is the famous Maimonides prayer about what true physicians were.  And it was summarized by Ed's statement last session about true physicianhood involves—and we talked about that this morning—a patient and a physician. 

But the physicians don't—true physicians don't operate by citing papers on professionalism.  All of us have a nomos, an ordering system, and it's fueled by what Dietrich Ritschl called implicit axioms.  These are little cognitive half sentences that drive what we do and don't have to be formally called out for examination.  I sometimes say, if I go into a store, I don't have to call out a full sentence that says, "Thou shalt not steal."  I mean, it's an implicit axiom. 

And all the true physicians through history that I have read about, and the current ones, operate with a set of implicit axioms that automatically tell them what to do.  Now... —occasionally you'll come to an ethical problem or something that requires expertise.  But the ordinary thing is fueled by this.  And as a consequence, I think that to continue to write, as many people do—I mean, that's good for a professional job, but I don't think it's important to physicianhood per se, that it's unchanged. 

Now, there's talk in the paper about hidden consciences, that physicians don't live up to what they do, and I'm sure that there have been pirates in the system for a long time.  My own impression is that the residents and students are much more positive about medicine now than they were twenty years ago, when we were in the midst of the yuppies and so forth and so on.

We just finished our residency review evaluation in the Department of Internal Medicine, and part of that is that the examiner meets with residents who are elected and poses their impression about what their training was about and what the physicians were—and it's really quite remarkable.  We haven't had the formal report, but the visitor said the residents were very positive both about the competence and the compassion of the faculty that were attending on their things.  They were not—they didn't come across as cynical and so forth.  So I think that many times in many medical schools and in many private practices, true physicians become the models that we follow.

The other thing we do is tell stories.  We heard that this morning.  We have a college system right now so that every medical student at Southwestern has a mentor that will be the mentor for six students for four years in medical school.  The mentors are our best teachers, and each college has a master, and I'm the headmaster of the whole thing.  But one of the things we've learned—we just started it this year—is that what they reflect to in these—we have a formal, two-hour session with them every Wednesday afternoon, with the mentor and the students.  And what they relate to is stories—stories of physicianhood.  And we tell stories.  And I think that's a good way to teach, in addition to living the story. 

Let me just give you one example.  Two Saturdays ago we had the White Coat Ceremony.  Those of you who work in medical schools know that a few years ago it got to be widespread that the freshman students would put on a white coat as a symbol of true physicianhood, that they would eventually get seven or ten years from now.  And I've been doing this at Southwestern for about seven years or something like that.  But let me tell you how this works. 

So I told them a white coat story.  And the white coat story that I told this time went back in history, and it was the day of John Kennedy's assassination, where he died in Parkland ospital, which is our main teaching hospital.  The chief resident in surgery then was the late James Carrico, who subsequently became our Chair of Surgery.  He'd been at Seattle, Washington, and was recruited back here.  He had been called down with another resident to the Parkland emergency room.  Parkland takes care of the medically indigent in Dallas.  And he had been called down.  There were two patients that needed surgery.  One of them had a mechanical intestinal obstruction, and the other had a thrombotic leg with gangrene.  Both needed to be operated on. 

While they were in the emergency room, the word came that the President had been shot.  James Carrico was the first person to see President Kennedy when he got there.  He immediately started fluids and started steroids.  As you remember, Kennedy had adrenal insufficiency, and he remembered it—the Parkland resident remembered that.  George Thorn was desperately trying to reach Parkland to give him the—he was gone—I mean, the steroids wouldn't help.  But he was trying to say—but it had already been done.  It was, as you know, to no avail, and the President died.  And after his family left with Johnson and the judge, they went to Love Field to swear in Johnson as the President, and Governor Connolly was still in the operating room. 

Then Carrico, the chief resident, came back down to the emergency room and took the woman, an uninsured Parkland patient, up to the operating room and operated on her.  And when he was through, he went home.  His white coat—he didn't tell me this till a year before he died at the AOA—he'd never told this story before.  When he went home, his coat was covered with blood, and it was a mixture of blood.  It was the blood of the President of the United States and the blood of an uninsured Parkland patient.  And in passing I told the first-year students, true physicians take care of the rich and the poor, the famed and the unknown, in the same way.  You see, it's a story that they get what true physicians do. 

When Jim went home, he felt something in his pocket of his white coat, and what it turned out to be—he reached his hand in—it was a piece of the skull bone from the President's head.  When they had tried to move his head to see what they could do, it had apparently just fallen off and slipped into his pocket.  He ate supper, and then he went into the back yard—he told me later he realized that he should've saved this, but he burned the white coat and buried the bone.  He burned the ashes and the bone of the President of the United States.  And then the next morning he put on a clean white coat, and he went back to Parkland. 

And I told the students, "That's what true physicians do.  They are not defeated by defeat."  He went back to what he did.  So one of the best ways to illustrate is to tell stories about true physicians as well as to live that.  And I think that's much better than writing papers about it.

Now, this last thing I want to say has to do—because, as David says in his paper, there are many things that we could discuss about professionalism or true physicianhood.  But my own view is—as we have a relatively short time—I mean, let's say another couple of years or a year or year and a half—I personally don't want to spend it on more talks and things about professionalism.  We've had some really exciting times here:  the stem cell conversations, the enhancement, the suggestion of how you might get stem cells and avoid the ethical problem.  We've discussed transplantation, trying to get organs. 

As we said last session, I personally think that it would be a stronger thing for the history of this Council to end up with a serious ethical problem.  I don't consider professionalism a serious ethical problem.  And what a number of us were concerned about, including the chairman, was the issue of health care in the United States, that is to say, particularly the issue that there is a large portion of our community, our larger community, that does not get adequate health care.  And I think we ought to focus on that. 

All I would want to say is that if we believe that—and a number of people don't believe that.  If you're poor and you can't get health care, that's just somebody else's problem.  But I think if we as a Council said for the—I wouldn't say it this way, but for arguably the best country in the world—we have our problems—it is not ideal that a large portion of our population cannot—if you live in Dallas and you've got Parkland Hospital, you're okay.  But if you live in a small town, in Desolate, Texas, you don't get—you know there's no—I think that's what we ought to do.  Not to meddle with Congress, not to do what the Presidential candidates might be talking about this, but simply to say we think a great country ought to meet its obligations to its people in terms of health, just as we meet the obligations to protect them from terrorism and all of these other things. 

So I want to end up with this:  having said that I think this is an excellent paper that's been written, it is not as important to me—and, I mean, I'm not—I think we ought to do something about this thing and end up where somebody could say of this Council they had lots of discussions, they disagreed all the way, occasionally Gazzaniga is telling us we're crazy about things, but we started with a serious problem, and we covered several other serious ethical problems, and we're going to end up with another ethical problem, and we believe that to be a great country, we ought to take care of the needy.

It's not just health care.  I mean, we have other problems, the homeless and all sorts of—but we ought to say that we are a country, like true physicians are, of compassion and that we want to—somebody else can figure out what to do with it.  That's not our business.  All we want is to go on record as saying this is something that we feel strongly about, if we feel strongly about it.  That's all I had to say.

CHAIRMAN PELLEGRINO:  Thank you very much, Dan, especially for responding to my request at the very beginning of the meeting that we ought to—and I hope the other Council members will be equally direct about which of these two—and they're not before us in this particular meeting—we should pursue and we can make a contribution to.  And thank you very much.

 I'm going to ask the other discussants to speak, and then we'll throw it open to general discussion to the Council members.  Our next commentator is Paul McHugh.

DR. McHUGH:  Well, I, too, found the paper very interesting, and I marked off a number of places where I thought good ideas were being proposed and all.  But, again, like Dan, I have concerns about writing theory about the practice of medicine, in the sense that it's just not the way we tend to work.  That's all.  What happens—again, Dan has said it in ways of story.  I want to put it another way. 

I want to say that medicine is one of those particular life experiences—the training in medicine—in which, through the practice, especially the practice under supervision and the practice with other people who support you in this enterprise, that you learn a lot.  You learn a lot that then some people, for the theory reasons, for good reasons, propose as the representation of what the practice means.  The best kind of theory, in other words, emerges out of practice, rather than that practice is generated by the theory.  If the theory is of any use, it's because it then becomes feedback to you in your practice. 

You say, well, this is close to what I mean.  And this gathers the frame of reference that we work under and that represents the kind of person I would like to be and that I would like a great physician like Dan to appreciate what I was doing in a particular way.  We have this frame of reference.  And then it sits there, modified further and developed further, as the practice and the reflections on practice from theory works out. 

I'm much more interested, in other words, as to what kind of a person medicine tends to generate in such a fashion that doctors, whether they be surgeons like Ben or great physicians like Dan or psychiatrists like me, fundamentally have—oh, we can disagree on certain things—we do have a kind of way of looking at what we're doing in such a fashion that, when we disagree, we know what to refer to, to solve that disagreement, what other kinds of experiences that we've committed ourselves to in which some person could say, well, I'm not sure we're living up to that. 

And so that was really the reason why this morning I was making a couple of points about what I want—what I think, really, the best physicians become like out of the experience they have of working under good supervision with other people.  And I was just thinking about what they were.  The first one, as I say, you ultimately have this—you take on this ability and willingness to take risks.  Now, usually it's not life-threatening risks, although every morning when I come into Johns Hopkins I have the little plaque to one of the wonderful men with Walter Reed who died in proving that yellow fever was transmitted by mosquitoes.  But you do take other kinds of risks—risks of time, risks of energy, risks of what you might think are your development.

Then the other thing that you get from this is the recognition of the common goods that medicine provides to the society that the expression of those common goods really—and the attempt to meet those common goods as a profession—produces an individual good for you.  You're made better because you're committed to the common goods that are shared within the group.

And then I think a very important part that you learn in this process of taking care of patients and being an intern, resident, and all, is that you really develop a desire to excel but not necessarily to win.  You're not doing this for—the best physicians aren't trying to get a prize doing this.  They're just trying to be damn good at it.  And they have their models of who's good at it.  But that's what comes from this, and that depends upon an ability to question your own judgment and to be a self-questioning person.  And ultimately, as I said, it's an attempt to develop that kind of integrity of your own desires that other people will trust you.

Dan's little picture of the—well, didn't win today, but I'm back at it tomorrow and coming to it—that kind of thing is part and parcel of the self-knowledge and self-development that medicine gives.  I happen to think that it's—there aren't very many exercises or practices in this world that develop that kind of moral agency in individuals after you've gone through it.  The great part of being a doctor and having the doctor's experience, I think, as you get through it—and it helps you in thinking about your moral agency in other responsibilities and other places.

But, like Dan, I believe that the greatest utility is to continue to talk—the useful thing is to talk about just how these kinds of achievements of moral agency, this kind of development, is worked out in practice, rather than give a large conception of what professionalism is.  In that way, in a small fashion, you might begin to argue a little bit about the present changes, some of them for the better and some of them not for the better.  I think that this gradual constriction of hours has a good side to it, because, as we said this morning, the technology is so much more advanced than it was when I was an intern, that I'm quite sure that the kind of exhaustion that was routine with me would make it rather difficult for me to be able to use as good judgment as you have to do with these new machines and all.

On the other hand, I think we're really—if anybody knows anything about these residents and interns, letting them off after eighty hours in the week, you're going to ask them where they went.  You're going to have to have a bed check to make sure they go to bed, because they don't go to bed.  They go out and do something else, sometimes even to moonlight in another place.  So in some way the search—and what I'm interested in is discussions over how various kinds of people relate to young students in this field so as to help them to gain the capacity to be doctors and in that process—rather than kind of professionalism writ large, in that process develop their characters and the like. 

And so I enjoyed this, and it's a nice little paper, but, with Dan, I'm not sure where it will fit in.  As I just wrote down, "Theory is a product of practice and strives to articulate the implications built into that practice in such a fashion as to be able to reflect back on matters of practice under dispute."  That's what I think the place of theory is.  And I'm sure you wouldn't all agree on what I consider to be the aims of this, the aims of professional education.  But it's those kinds of things, practical things, that I would like to see articulated in a paper.  Thank you.

CHAIRMAN PELLEGRINO:  Thank you very much, Paul. Ben? 

DR. CARSON:  You know, I find the discussions about professionalism very interesting.  And I would have to agree with Dan that nothing has really changed very much in that realm.  But something has changed very significantly, and that is there are a lot more impediments to professionalism now.  And they seem to be continuing to be compiled on a daily basis by a slew of self-interest groups and bureaucrats which have insinuated themselves into the doctor-patient relationship.  This is actually a very serious problem.

But of much more profound importance, I think, is the whole issue of healthcare access and also the great disparities that exist within our society, for instance, in the African-American population, huge disparities, and most of us look at it with our intellectual glasses and say, yeah, that's a shame, and then we move on.  I'm not sure that responsible government should ignore such disparities, particularly if there are things that can be done about them.  I think we perhaps have the ability to bring this to a level where it can no longer be ignored. 

And also the whole issue of healthcare cost—when we start looking at amount of our economy that is dedicated to health care, it's a staggering amount of money.  It's far more than enough money for everybody to have excellent care, and yet everyone does not get excellent care because of the enormous amount of abuse and waste that we simply wink at and tolerate and don't really have the courage to attack those entities which are wasting the people's money.  So that would be my comment on this.

CHAIRMAN PELLEGRINO:  Thank you very much, Ben.  I'd like to open the question now to the members of the Council.  And this is an important point:  please express your thoughts about whether we should or should not proceed further on this particular topic.  So I see a hand.

DR. BLOOM:  Well, just to get all of the medical points of view on the table at one time, I'm in full agreement with Dan's desire that we concentrate on the subject we'll talk about tomorrow, which is the problems with the current healthcare system.  But it strikes me that there are many aspects of the points described in the Miller paper that could be brought into that broader discussion on the current concerns, including what Ben just mentioned about disparity in health care.

I'm reminded of Dr. Leach's comment when we met the last time, that we've grown to tolerate these constraints, and it's not far away from the anecdote our speaker this morning talked about—getting on your rocket ship and going to another planet and then ignoring everything that happens there because it's not real.  I mean, we know that the current situation is bad and growing worse and more costly, and yet we tolerate it, and we have to stop tolerating it.

CHAIRMAN PELLEGRINO:  Thank you very much, Floyd.  Bobby?

PROF. GEORGE:  Yes, thanks, Ed.  I just wanted to follow up something that Ben said and ask Ben some questions, because I think this is the first time at least I've heard the access issue discussed in terms of problems of waste, fraud, and abuse.  And I think if Ben's right there, then that's a very important connection that's got to be explored.  And so Ben, if I may ask, to explore that question properly, would that have to be done at the retail level, or could it be done at the wholesale level?  In other words, would it have to be done with a kind of Grace Commission type operation that examines each institutional provider of health care, or could anything useful be done—I'm not saying by this Council, but by a Grace Commission type inquiry into the general problem, if it's one that transcends many institutions, to see if there were guidelines that could be formulated that would at least minimize to the extent possible—I realize you cannot drive waste, fraud, and abuse completely out of anything—but minimize, to the extent possible, waste, fraud, and abuse, especially as it bears on access.

DR. CARSON:  Well, I would not claim to have all wisdom in this area; however, I don't think that it takes a great deal of analysis to recognize that when we are taking so much of the healthcare dollar and paying entities that don't need to be there in order for good health care to occur, that act, in and of itself, deprives many people of the health care that they should be getting.

What do you need for good health care?  You need a patient and you need a healthcare provider.  Now we've created an entity to facilitate that health care which is much bigger than the patient or the healthcare provider and which sucks the life out of the system.  I don't see why we need a Grace Commission to make that point.  I think people who talk about this tend to be personae non grata sometimes, but the fact of the matter is, if we don't talk about it, our system will continue to deteriorate, particularly as the population gets older, and more and more people need health care, and fewer and fewer people have access to it.

PROF. GEORGE:  If I could follow up with Ben, is a significant part of the problem regulations by various levels of government that result, by the law of unintended consequences, in unproductive uses of resources, and then, second and parallel to that, to what extent is the problem needing to meet the demands of insurers and the overall insurance system?  I'm wondering to what extent the problems are there and not actually in the institutions just as such themselves.

DR. CARSON:  Well, you're hitting at the crux of the matter here, because—and, again, I'll keep harping on the same topic, because—a good healthcare provider and a patient—and what we've done is we've insinuated all of these regulators into that relationship with the proclamation that they have a much better and saner approach to health care than your physician would have.  And I think there's the rub.  And what we really, in my opinion, should be looking for are ways to reduce the cost—and it comes back down to a cost issue when it comes to access—reduce the cost to a level where people can afford their own health care.  And then, very much like they do in Scandinavia, it would not then be unreasonable to require that people own healthcare insurance. 

It is unreasonable at this stage, because the cost is way over-inflated.  It doesn't need to be anywhere near that high if we get these unnecessary entities out of the way.  And I do believe that those interfere.  The desire of hospitals now, the desire of physicians to get an A from all of these regulators, so that they can be "the good people and the best people"—this is ridiculous, and this doesn't have anything to do with good health care.  People will know themselves when they're getting good health care.  And market forces will lead them to people who provide that good health care if we remove all the impediments from the way.

CHAIRMAN PELLEGRINO: Dr. Gazzaniga?

DR. GAZZANIGA:  Well, I'm Mr. Blunt here, I guess.  I've come from a medical family.  I have a father who is a physician, went to Loyola.  My sister went to Loyola.  My brother went to Dartmouth.  My two nephews went to Dartmouth Medical School.  And all of them—all five of them—have a stance, and their stance is that their moral stance is not what the patient is interested in.  The patient is interested in medical service.  And the physicians are the ones licensed to provide it.  And when you go to see a doctor, you really don't care about their moral stance.  You want their best medical thinking on how to deal with your problem. 

And it seems to me that that is a fundamental part of this equation that we've been talking about:  the moral stance of the physician.  Well, there's the moral stance of the patient, too.  The patient's moral stance is I want intellectually bright and current service.  You are the provider.  Provide it.

But, having said all that, that's not what we're about here on this Council, as far as I can see.  If we go back to our original charge, we are to deal with the biotechnological developments that impact the public.  And it doesn't strike me as how you're going to handle the profession of medicine as one of those.  What is relevant is this other issue that keeps popping up and I just want to put my two cents in on supporting.  Certainly biotechnical developments are going to allow for genotyping of everybody fairly soon, and it's already done, but on a mass basis, and so everybody—everything is going to kind of be known.  The risks of people are going to be known.  They won't be private; they'll be known. 

And once we move towards what's known about us, where the devils lurk in our future, it just follows that we need single-payer health care, but one can't imagine any other system.  I in my own family have a niece who I know will need a $40,000 biochemical treatment every year for the rest of her life because of a certain thing she has, and how else can that be provided other than by a system that says we're going to provide it?  You can't hang onto the parents' insurance past the age of 23 and so forth.  We all know the problems. 

So, anyway, it is such a clear issue, and you can come at it now politically and socially and morally and all these other questions, but the fact that's coming down the pike from the biotechnology community is we're going to know everything about you and where you're probably—what you're going to probably die of.  And that being known, you can't let that fall into the private insurer's hands, who can eliminate you from coverage.  So we've got to go to some kind of single-payer system.  We've got to have a system that says we're going to care for each other.  How we do it, I have no idea.  That's another issue.  But that we have to do it seems to be clear.  And I think that's what we should concentrate on.

CHAIRMAN PELLEGRINO:  Thank you very much, Mike.

DR. HURLBUT:  Mike, I want to understand what you're saying exactly, because it strikes me as very important.  You're saying that once we have the capacity to individually, personally discern the genetic sequence of every patient, either the whole thing or the salient markers, that we will then be able to predict their medical future, so to speak, their history in advance?

DR. GAZZANIGA:  We will be able to predict all kinds of things about the probabilities of contracting certain diseases.  That's where it's all going.  And so if you have a certain allele situation, you're going to obviously—this is all knowledge that's unfolding now.  I'm not saying I have a book here.  But there are things that are known—that that's going to just be very telling about your future health probabilities.  And once you have that—disease probabilities.  Once you have that, people are going to steer away from you if you have this sort of genotype versus that, and that kind of problem I see as coming down the pike.

DR. HURLBUT:  Well, I want to understand what you're saying, because in fact the medical outcomes will be the same as when we didn't have that information, except where we can intervene—

DR. GAZZANIGA:  Well, when you're going to take someone on to insure them.

DR. HURLBUT:  Well, that's what I'm asking.  Is this what you're saying is that it'll throw the whole issue of insurance into disruption?

DR. GAZZANIGA:  Yeah, I think so.

DR. HURLBUT:  So—

DR. GAZZANIGA:  It's just a prediction, but I can't see—under the current system there's all kinds of ways people are being excluded from medical insurance now, so it would only compound the situation.  Correct me if I'm wrong, but that's how I see it.

DR. HURLBUT:  Well, I mean, I do—I'm not the one to correct you, but I do have some doubts about the ability of our genomics to predict so specifically such a large amount of data as you're implying.  But be that as it may, I don't doubt that there will be proclivities and statistical data correlated with genes.  The informatics of that will be so complicated, it'll take generations to correlate it.  You have cases where you have even identical twins with quite different medical outcomes, even for things with single nucleotide differences.  So obviously the equation is not simply your genetic heritage; it's your environmental encounters and a lot of stochastic events, and it's going to be very complicated.  So we shouldn't overimply on the record here that genetics is determinative. 

But your point isn't really that, is it?  It's just that you're saying that with a lot of information and maybe even misinterpretation of that information, in the sense that it's more determinative than it ought to be—interpreted as more determinative—that there's going to be a discriminatory—or a parsing, if you will, of patient populations with insurance.  That's what you're getting at, if I understand.

DR. GAZZANIGA:  Yes.  And on the former point, that it will be a complex science full of tremendous charges to the field of informatics, that's absolutely true.  But help's on the way.  My daughter is a graduate student in genetics, and I think she's going to whip this one out.

CHAIRMAN PELLEGRINO:  Other comments?

DR. FOSTER:  Could I just respond to that thing very quickly?

CHAIRMAN PELLEGRINO:  Yes.

DR. FOSTER:  We already know, for example, that there are DNA repairase genes that predispose to familial cancer, and you have to—the third leading cause of death is now pancreatic carcinoma.  The Johns Hopkins has the single center that I know about that follows familial pancreatic cancer, and what they do is they take secretions from the pancreas, look for biomarkers and so forth.  I mean, we're not going to solve all of these things. 

But already, I mean, there are many genetic things that require ongoing testing if you want to try to save your children's life or things of that sort from the thing, and they're all expensive, and you're not—if you get knocked out because you have had familial breast cancer, nobody in your family can get insured again—we already see that, as Mike was saying.  It's probably against the law, but we still see it.

And we've said this before—I mean, the insurance companies also have to—if they know that they're going to cover a lot of people with high risks, then there's no way that the premiums are not going to go up.  I mean, so you have to solve that.  Now, there are several other approaches you could take.  I mean, you could stop marginalization, things for marginalization, that is, doing whole-body scans and to live two months longer for colon cancer at $100,000 a year—you can do that, or you can take the Oregon view and say we're only going to treat certain common diseases.  I mean, the solutions are not there.  But I think that what we're trying to discuss here is whether this is something that we as a Council ought to do.  That's the last thing I'm going to say.

CHAIRMAN PELLEGRINO:  Thank you, Dan. 

PROF. SCHNEIDER:  I have more thoughts about this than I have been able to straighten out, but let me just say a couple of things.  First, I would be truly tickled pink if the kinds of ideas that Ed laid out last time could somehow be put into practice in medicine.  And I agree with Dan that the kinds of ideals that Ed is talking about have been enunciated, often less effectively, for a long time.  And so the question in my mind becomes whether there is anything you can actually do to make doctors more like the kind of doctor that Ed describes. 

I think that there is something to be said about the current—or at least one of the current favored solutions, which is, as usual, to say to the school, well, if you'd just educate people better, all will be well.  I think there is an awful lot of silly thinking about what is going to be taught and how it is going to be taught in medical schools.  And as I said before, I think no matter how magnificently you teach these kinds of things in medical schools, if doctors get out into the world in which they practice and find that what they were taught in medical schools is disadvantageous, dysfunctional, damaging to them, they will behave differently.

This leads me to wonder how you do—if education doesn't work, how you do reach the world that Ed describes.  And we really haven't said anything about that, I think.  Let me say a word in favor of bureaucracy and regulation.  First of all, bureaucracy is here because that is the only way that you can organize large-scale human enterprises.  Durkheim and Weber were cited this morning.  Dukheim and Weber said this a long time ago, and every year it gets truer. 

So it seems to me that the real question here is not how wicked bureaucracies are; it's how do you make bureaucracies function effectively in the ways that you want.  I think an awful lot of the actual ethical problems that young doctors and young lawyers, for that matter, have aren't so much with doctor-patient relationship or lawyer-client relationships.  It's how to work in the bureaucracy in which they inevitably find themselves.

The next question I would ask is why do we have all of this regulation and all of the other things that we have often heard get in the way of the practice of medicine, and I think the short, short answer is because things have gone wrong.  And the regulation and the bureaucracy are directed to trying to deal with those sorts of problems, and it's very difficult to make bureaucracies work the way you want to, and it's very difficult to make people change their behavior when they have lots of reasons for the way they're behaving. 

So I think that a really serious look at the professionalism question would lead you to be looking at those kinds of issues.  And I'm not sure how practical that is.  I think it might be possible to say something about the role that organized medicine has had in dealing with these kinds of problems, a role that seems to me to have been very disappointing in failing to address the kinds of problems we've been talking about in the kinds of ways that I've been suggesting, and then this leads me to my second point, and that is to agree with what several other people have said.

For the record, the figures that were cited earlier, the current estimate is 46 million people are uninsured, and that is in some way a misleading figure, because a lot of those people don't especially need insurance.  But the trouble is that a lot of other people are underinsured very significantly, and they are often in much worse shape than people who are uninsured altogether. 

The other figure that we were looking for was that currently about 16 percent of the gross domestic product is devoted to medicine—health care—far more than any other industrialized country, with no evidence of any better care.  And it seems to me that this is a topic worth pursuing, not because there's anything very new or interesting to say about it—I mean, these issues have been gone over at least since Harry Truman was President and proposed a solution to this kind of problem. 

But it seems to me to be wrong for an organization asked to think about bioethical issues not to at least draw the country's attention once again to the extraordinary urgency of the problem of access to health care.  And also speaking as a bioethicist, I think it would be a salutary thing for the field of bioethics to be reminded that there are issues besides the one or two or three that they're interested in, and that a lot of those issues are far more important than the issues they're interested in, and the most important of these is access to good health care.

CHAIRMAN PELLEGRINO:  Thank you very much, Carl.  Further questions, comments?  Dr. Dresser?

PROF. DRESSER:  To be very concrete, is there a need to set priorities?  That is, is there a sense that we would not be able to do reports on both the working paper today and the working paper tomorrow?

CHAIRMAN PELLEGRINO:  Just an offhand response, and don't hold me too strictly to it—I think we could in the time remaining do something on both, if that's your wish.  I would like to know where are they and where we would move from.  But I think we could do both, if that's the wish of the Council.

PROF. DRESSER:  Well, I agree that first priority should be tomorrow's topic.  If we do something on this topic, I would hope that it would be more focused on perhaps stories and cases as illustrations.  If this is directed to the public and perhaps some clinicians, I think a way to reach them is through examples and compelling stories such as the ones that we've heard—how to be good clinicians in today's climate—and use that to reach any abstract principles and so forth as Paul has said.  I think that would be much more likely to reach the audience and more interesting for us. 

And I also, though, agree with Carl about the role of medical organizations and possible contributions that could be made in that way that haven't been made.  So I would be interested in pursuing that part of it as well.

CHAIRMAN PELLEGRINO:  Thank you, Rebecca.  Let me say in my answer to your question, there's nothing to suggest that the two subjects are mutually exclusionary, so that we could conceivably discuss one background or the other. 

PROF. DRESSER:  Yes, I agree.

CHAIRMAN PELLEGRINO:  And I think there are connections that I could think about.  So let's not exclude that possibility.

PROF. SCHNEIDER:  Just one small observation—I wonder what this question would look like if we thought about it not from our point of view but from the point of view of the average patient in the United States.

CHAIRMAN PELLEGRINO:  It's one of the things you'd have to look at in the whole story.  I mean, I wouldn't want to answer that offhand, yes or no, but—

PROF. SCHNEIDER:  It's always seemed odd to me that we sit around defining the agenda of groups like this and of scholarly enterprises like bioethics mostly in terms of how intellectually stimulating we find them, and I've often wondered how we would explain ourselves if a panel of patients asked us what we were doing with our time to help them.

CHAIRMAN PELLEGRINO:  Peter?

PROF. LAWLER:  All right.  Surely both topics are important.  This professionalization thing seems to me to be a little bit generic.  I'm not convinced it's specific to the medical field in particular.  According to the great theorist Karl Marx, the bad thing about capitalism—and there are many good things, like conquering scarcity—but the bad thing about capitalism is everyone is reduced to a wage slave.  And so that means it's not so much professionalism is threatened, but as Paul and Dan remind us every day with their words and their example, the nobility of professions is threatened, the sacredness.  As Marx says, our halos are ripped off. 

But the cause of this, it seems to me not to be well—although this is a very fine paper in many ways—the cause just seems a little bit muddled.  So on page 11 near the bottom—five lines from the bottom—"can or should"—and, of course, the "or should" is rhetorical, because surely you should resist all these bad things—"can or should medicine resist the great contemporary American ethos of individualism, commercialism, scientism, technologism, entrepreneurialism, marketization, bureaucratization, proletarianization"—which seems to me a bit extreme, really—the great mass of unwashed MDs who get paid—and I know your salaries are going down, but you're getting a little more than subsistence even now.  And also these things—the entrepreneurialism and bureaucratization are opposites, all right?  The entrepreneur doesn't like bureaucracies. 

And it's not clear to me whether the threat to professionalism is the market eating up everything or bad regulations of a certain kind, too much government involvement of the wrong kind, because managed care is not entrepreneurial care.  Even Ben said that if we could free these guys up some, then consumers would pick the best doctors again and all that.  So the problem to me—and I'm not an M.D. and don't really know what the threats are, and I don't even know what "professionalism"—well, that doesn't mean I don't do a good job, but the very word "professionalism" eludes me.  At the end of the day, I'm not sure we have focused this thing that well on what a profession is. 

For example, this morning we had this big dispute between Paul and a really fine speaker, who wanted the well-balanced life versus the noble, heroic risk-taker.  And the man said the age of the heroic doctor is over.  But that couldn't possibly be really true, because it's not the—so the heroic doctor is not replaced by the proletarian doctor; he is replaced by the well-balanced, bourgeois, bohemian doctor.  And I think the heroic doctors will continue to emerge.  I think the threat is exaggerated.  I am absolutely certain things are all messed up, partly because of market forces and partly because of really bad regulations, and we're spending way too much money for way too little.  I mean, all these things are clear to me.  I don't have the technical expertise to fix them.  But of the two topics, I think the one tomorrow is the one we should consider more taking on, or we're going to have to work on what this professionalism issue is with greater focus.

CHAIRMAN PELLEGRINO:  Thank you very much, Peter, and particularly for the clarity of your suggestion and your decision and priorities, or recommendation.

Alfonso?

PROF. GÓMEZ-LOBO: This is just a personal reflection, and it's very much determined by my own limitations.  I must confess that the issue of professionalism is something that escapes me in many ways.  In fact, I tend to see it like Peter.  I see that there are these enormous forces gravitating not only on the medical profession but on other professions, so that I just don't see at the moment a reasonable way to tackle this as a problem in ethics.  I don't think it's a problem of good will.  I'm not sure that certain forms of reforms of medical education would do it.  I'm with Carl on that.  I think it's just a problem of enormous, enormous complexity for a Council like this one. 

On the other hand, I do think that there's a clear ethical problem on the other issue, and it's not just because a great country should do it, it's because any country should do it.  In other words, there is something really, really ethically unacceptable in having 46 million people without insurance and therefore with limited access, because of that, to health care.  It seems to me that's very important. 

And I wanted to side with Mike, for once, on that issue.  It seems to me that you're absolutely on the right track.  Why?  Because if I put myself in the shoes of a businessman who has an insurance company, the first thing I would do would be to try to find as much information as I can to get rid of those people who have even minimal risk.  I mean, not that we know everything that's going to happen to them, but if I could purchase somewhere a list of the people who are prone to have certain illnesses, oh, I would get rid of those the very first.  Just as if I had an insurance company that insured automobiles, the first thing I would do is get rid of the bad drivers, so I would get rid of most teenagers, for instance, or charge them double or something like that. 

And we're—now, Nick is probably going to correct me on this, but it seems to me part of common sense today that things like medical insurance simply, simply should be part of the communal enterprise.  It should be part of the community.  It's what the Scandinavians do.  It's what the Europeans do.  I've been told that some of their systems are not great.  Fine.  But the system is there.  Now, summarizing, then, I'm very much in favor not of going into the nitty-gritty questions of how you design health insurance, but to put in front of the American people the urgency—the moral urgency of solving this very basic problem in the United States today.

CHAIRMAN PELLEGRINO:  Thank you very much, Alfonso.  Just for clarity on a few things I've said—I share the distaste for the term "professionalism" that some of my colleagues have mentioned.  None of what I said at the last meeting, in my view, would be a defense of professionalism.  I find the term abhorrent.  My own interests are somewhat different.  To look at what are the moral foundations of a profession is an entirely different question.

The second point that you made, Alfonso—I think others have made, too—I'd certainly like to say that I don't think it's impossible for us, as the kind of group we are, to ask the question: Is there a moral or ethical obligation, and not get into the business of how you do it? That's a terribly complicated [issue], which we all know is a matter of public debate right now, and we don't need another group diddling with the system.  But we do need someone saying we have a [moral] obligation [as a nation] to address this problem of equity or however you want to put it. 

I'm not trying to phrase the question so it comes out in a particular way.  But the fundamental question is: What kind of society do we want to be?  And that's a much bigger question than how you diddle with the system... Nick, I have you on the list.

DR. EBERSTADTThank you, Ed.  First I want to warn Alfonso, if you only charge the teenagers twice as much as everybody else, your insurance company is going to be out of business really soon.  I wanted to say a word about the question of medical costs and the historically unprecedented level of GDP that our healthcare system absorbs at the moment.  And I wanted to offer just a word of caution about that.  I don't want to be a cheerleader for waste, fraud, and abuse, but I want to suggest that even if it were somehow miraculously possible to eliminate all waste, fraud, and abuse from the U.S. healthcare system, we would very likely see an unprecedentedly high share of economic resources going to the healthcare system and only further increases in shares likely on the horizon, because shares of GDP have to add up to 100 percent, and if we look at what's happened in the United States over the last forty or fifty years, one of the big things that we've seen has been a steadily declining share of consumer resources allocated to food. 

Back in 1960 about a quarter of consumer spending was devoted to food.  Today it's less than half that, maybe around 12 or 13 percent.  And everything has to add up to 100 percent.  We've seen the share of GDP devoted to vacations and travel triple or quadruple over the past two generations.  We don't see that as a crisis, because we think that the consumers are deriving some sort of benefit from their selections in these areas.  Similarly we've seen a great increase in the proportion of the GDP that goes to investment over the last century.  We don't see the doubling of use of output for investment as a crisis, even though there's probably a lot of waste, fraud, and abuse in what we call investment as well.  In principle, investment stands to advance the economic good and the common weal. 

With the United States in particular we have such an intensity in the use of new technologies in our medical and healthcare system, that it might not be surprising, even in the absence of waste, fraud, and abuse, to see healthcare costs somewhat higher in the U.S. than in some other affluent societies.  We all know how expensive and clunky little calculators were at first and how the prices tended to come down when they became more routinized.  There may be some analogies to certain parts of our healthcare services. 

In short, even if it were possible to radically reduce or restrict waste, fraud, and abuse, my guess would be that over the decades ahead we might still end up seeing health care absorb a higher and higher fraction of total economic output, and that wouldn't necessarily require services of the Inspector General.  Thank you.

CHAIRMAN PELLEGRINO:  Thank you very much.  Diana?

PROF. SCHAUB:  I'll say something about my reaction to the doctoring topic and leave a comment for health care for tomorrow.  I very much like Dan's phrase, "true physicianship," and that seems to me an interesting topic.  I would like to know what it means to be a true physician in the same way that I'm interested in knowing what it means to be a true teacher.  So I do think there are things there worth exploring—the moral foundations of doctoring and whether and how those are being eroded.  But the fact that all of the doctors who have spoken on this topic are dubious or have some reservations about pursuing it makes me also doubtful that we should go forward with it. 

So I do have a kind of suggestion.  I mean, maybe instead of a report we could send our storytelling doctors on the road.  I mean that somewhat seriously.  I mean, I don't think there could be anything more inspiring or ennobling than sending you folks out.  We've talked about other ways in which we might pursue our educational mission as a Council, and maybe something like that would work.  Or another alternative might be to do something more along the lines of the dignity volume, where we commission essays on true physicianship that would involve, as Rebecca said, this sort of storytelling.  And something like that might be able to—whoever makes decisions about curricula at the medical schools, maybe that could be a volume that would be of use.

CHAIRMAN PELLEGRINO:  Thank you.  That's an excellent suggestion, Diana.  Rebecca?

PROF. DRESSER:  I also think that's a wonderful idea, but I would say let's include nurses and other people involved in caring for patients.

CHAIRMAN PELLEGRINO:  Mike?

DR. GAZZANIGA:  A couple of questions for others to answer, because I don't know the answer.  Why is health care, covering the uninsured, a political question?  I've just never understood that.  And secondly, given we're all going to be happily covered someday, it's already going on that there's a whole class of physicians who won't take Medicare reimbursement.  They don't want to deal with it.  So while we're working to get people covered, is there within the profession a separation effect occurring that the doctors won't take the money and the so-called—the insured will not be covered?  I don't know the answer to either one, but I think they're interesting issues.

CHAIRMAN PELLEGRINO:  Dan?

DR. FOSTER:  Just in response—you know, you go to jail if you let somebody pay additional money if you're covered by Medicare, and you have to be covered—even Ross Perot is covered by Medicare, because he might need it some day.  But if there's a procedure—I mean, this is just—I shouldn't talk about it—but if there's a procedure, and the doctors can't get paid for it, they cannot be paid to do it from private funds, from a savings account or whatever, which would then probably help people—it's in every big city, as Relman said.  It certainly is true in Dallas.  You cannot get—the only place that's taking Medicare in Dallas is the medical school.  We had one cardiologist close his practice, and there were 1,500 people with Medicare who couldn't get care, and we had to take them.  It's devastating to our group practice as well.  I mean, my patients have Medicare. 

You wouldn't believe—I mean, if we take our two dogs to the veterinarian just to get shots and bathed, it's $250 cash up front.  I see a patient, and I'm a pretty well-known physician, and I get $43.00, and I don't take ten minutes to see them.  I go ahead and see it, because I work on a salary.  So there are a lot of things that you have to do.  But when you get to be Medicare age, which I hope will be a little bit longer than this, it's big time. 

And further, let me tell you one other thing, because I have a son who is a general internist, and his income has gone down every year for four years.  He's a general internist, and he's voted the most popular general internist at Baylor ospital and so forth.  Nobody goes into general internal medicine anymore.  We graduate 55 residents every year, and all of them are going into subspecialties where there are procedures that you can—you know, you do colonoscopies, you'll do fine.  Do chemotherapy—but if you just have brains to see it, you get nothing.  And so we had—I think we had five people out of 50 or 55 this year that are going to go into general internal medicine. 

So everybody's going to be a family practitioner instead of an internist.  Maybe that's good, maybe that's bad, but that's another problem.  It's not just Medicare, because it's the total things that go on.

CHAIRMAN PELLEGRINO:  Ben?

DR. CARSON:  But what Dan just described is an example of what I was talking about before when I talked about it's not so much professionalism as it is the impediments to practicing in a professional manner that has become extraordinarily discouraging.  I remember a case last year of a little baby from Louisiana who had a very, very complex problem, was a Medicaid baby, and I wanted to take care of the patient.  We managed to raise some funds, because it was going to require lots of different services, more so than just neurosurgery, and only to be told that, as you mentioned, because the baby was in a government program, that it would not be possible to utilize those funds to take care of that child. 

You know, these are ridiculous things.  And I'm not sure that that was really the intention, quite frankly, when many of these programs and these bureaucracies were put in place.  Obviously it was done with good intentions, but the problem with bureaucracies and government programs is, when they've outlived their usefulness, nobody ever gets rid of them, so they continue to exact large amounts of money while they're not really doing anything except creating problems. 

And I'm not saying that all bureaucracy is bad and that all regulation is bad; I'm just saying that a lot of it is, and some of it needs to be dealt with, and we need to update things, because there's a lot of progress being made in medicine—you know, we're learning new things, the genome project—all these things are coming along.  They're new.  We need to update the systems along with the things as they come and not just add new ones to it, which costs even more money.


  - The President's Council on Bioethics -  
 
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