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Meeting Transcript
September 9, 2004


Hyatt Regency Crystal City at
Ronald Reagan Washington National Airport
2799 Jefferson Davis Highway
Arlington, VA 22202

COUNCIL MEMBERS PRESENT

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

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

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

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

Michael S. Gazzaniga, Ph.D.
Dartmouth College

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

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

Alfonso Gómez-Lobo, Dr. phil.
Georgetown University

William B. Hurlbut, M.D.
Stanford University

Charles Krauthammer, M.D.
Syndicated Columnist

Peter A. Lawler, Ph.D.
Berry College

Paul McHugh, MD
Johns Hopkins University

Gilbert C. Meilaender, Ph.D.
Valparaiso University

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

Michael J. Sandel, D.Phil.
Harvard University

Diana J. Schaub, Ph.D.
Loyola College

James Q. Wilson
Pepperdine University



INDEX


WELCOME AND ANNNOUNCEMENTS

CHAIRMAN KASS: Good morning.  Welcome to members of the Council, welcome to staff and members of the public to this, the 18th Meeting of the President's Council on Bioethics. 

SESSION 1: NEUROSCIENCE, BRAIN, and BEHAVIOR VI: NEUROSCIENCE AND THE LAW

This morning's opening session returns to the topic of Neuroscience, Brain, and Behavior, a topic that the Council has been looking into in various guises over the last six months, informed by the belief that research on the human brain, anatomical, physiological, genetic, pharmacological, that this research is likely to be of profound importance both for human self-understanding, and also for the interventions based upon that knowledge that could do much to relieve human suffering, enhance performance, and control human behavior by working on its neural substratum.   The Council has been looking into important ethical issues likely to emerge.

Thus far, we've had sessions in which we had a general overview of some of these likely ethical questions, a discussion of the neuroscience of moral judgment, Jonathan Cohen; a review of normal brain development and the early development psychologically of cognition and temperament, Tom Jessel, Elizabeth Spelke, Jerome Kagan.

At the last meeting we looked at some specific issues.  On the technical side, on the side of intervention, the use of precise brain ablation and deep brain stimulation in the treatment of intractable behavior disorders, Dr. Cosgrove.  And using a case study thinking about the importance of the knowledge itself, the use of neuro-imaging and the assessment of psychopathology and personal responsibility.

At this meeting we continue the discussion of the last topic, turning to the subject of Neuroscience, Violent Behavior and the Law.  This topic has already been attracting a fair amount of attention, and you have at your place a new publication hot off the press, "Neuroscience and the Law: Brain, Mind, and the Scales of Justice", a AAAS Symposium published by the Dana Press.  It contains an article by our colleague, Mike Gazzaniga, and also by one of our speakers today, and Brent Garland, who is the editor, is with us today.  And thank you very much for providing council members with these copies.

This topic of science and law is not a new topic.  In approaching human behavior, science and law have different objectives and interests.  Science seeks to understand it, law seeks to judge it wisely.  The law which both teaches, and embodies, and enforces the community's shared moral norms and practices seeks to protect the community against dangerous and unacceptable behavior by judging misconduct and punishing offenders.

Although understanding and judging are different activities, efforts to understand criminal behavior and its causes continue to exert an influence on how society deals with criminals, not only in considering guilt and innocence but, for example, in sentencing, decisions about parole, proposals for mandatory treatment, as well as in growing communal efforts to prevent people from becoming criminals in the first place.

In previous generations, science and pseudoscience had been used by people to try to explain why some people commit crimes and others do not.  There were eugenic explanations, there was phrenological explanation.  We've been through a period of psychoanalytic explanations, and socioeconomic explanations, as well.  Today and tomorrow it looks as if neuroscience is going to be one of the major roads of explanation.

And although, as we all know, the law generally holds people accountable for their actions, various accommodations have been made in the past to the findings of those who offer explanations for misconduct.  The criminal law already accepts legitimate excuses that can lead to verdicts of not guilty; for example, by reason of insanity.  It considers mitigating factors in determining sentences.  It uses medical treatments that are made conditions of parole; for example, chemical castration for pedophiles.  And it seems easy to imagine how similar kinds of accommodations and adjustments might be granted for brain-based explanations, should these be forthcoming from neuroscience.  And as the staff working paper and your briefing book points out, neuro-imaging data has already begun to find its way into criminal trials, notwithstanding the immaturity of these findings.  So it seems that it's not premature for us to try to see where we stand on this, and where we might likely to be going in the future.

And to help us with this discussion we have two sessions planned this morning, one from the side of law and one from the side of science.  To begin with, the understanding of responsibility and the approach to judging, punishing, treating, and paroling offenders, and the contributions and challenges of neuroscience.  And in the second session, what can neuroscience contribute now and soon to our understanding of impulsive, violent, and aggressive behavior.

To help us get started on these topics, we're very fortunate to have two very special guests, Professor Stephen Morse, who is the Hubbell Professor of Law, and Professor of Psychology and Law and Psychiatry at the University of Pennsylvania Law School.  His paper from the AAAS volume is in our briefing book, and we presume that it has been read.  And he will make the presentation of the opening session.

Also present with us already, and the speaker in our second session, is Dr. Emil Coccaro, who is the Director of the Clinical Neuroscience and Psychopharmacology Research Unit in the Department of Psychiatry at the University of Chicago. 

Welcome to both of you.  We're very grateful for your presence, and look forward to your presentations.  And let me turn the floor over to Professor Morse.

DR. MORSE:  Good morning, and thank you very much for inviting me to be with you today.  I'd like to start by thanking the AAAS and the Dana Foundation for the opportunity to write about something very directly that I've been writing about more or less directly for about 10 years.  I very much appreciated that opportunity.

The basic message which I want to start with in my presentation is very simple.  We are conscious, rational, and intentional creatures.  That's what we are as biological beings.  Many people think that the task of the neurosciences is somehow to explain that away; that is, to suggest that our mental stuff, our conscious, rational, intentionality is simply epiphenomenal, and that it does no causal work in explaining our behavior whatsoever.

I think the task of the neurosciences is just the opposite.  I think it is to explain precisely how it is possible that a bunch of gray matter up here produces conscious, intentional, and potentially rational creatures.  And that is the task for the neurosciences; not to explain us away, not to just make us a bunch of biophysical mechanisms, although gosh knows, we are biophysical mechanisms to begin with, but to explain how it is that creatures like us are possible.

Now in some people's lexicon, that's called the mind/body problem or the consciousness problem, some people think it's not soluble.  I'm open-minded about that, maybe it is.   And as Dr. McHugh has said famously, that if we ever figure out how the brain enables the mind, it may completely revolutionize our understanding of ourselves as human creatures.  But until the doctor comes, as Jerry Foder says, if we're sure of anything, and as much sure of this as we are of the existence of mid-size objects in our universe ranging from tables to planets, that we are conscious, intentional, and rational creatures.

And I want to start off with a case of my own, something that's adverted to in the Commission's working paper, the case of Herbert Weinstein, who is known previously in the literature as Spyder Cystkof.  By the way, I should say about the Commission paper, that a lot of the cases in which the neural imaging evidence was admitted were trial level cases, trial level decisions that have no strong precedential value.  Indeed, they have no precedential value whatsoever.  It is still an open question how much neural imaging or other forms of neuroscientific evidence will be admitted in courtrooms for purposes of deciding about responsibility.  I'll be talking later about the relevance of this material.

So Spyder Cystkof was a 64-year old semi-retired advertising executive.  He was married to a woman who — and this is all, of course, pseudo-anonymous — called Brunhilde.  They were both on their second marriage.  They were having an argument one evening.  They were each, as it were, dissing the children of the first marriage, which tends to make people very unhappy, and they got into a brawl about it.  And when Spyder would start to get angry, instead of fighting, he withdrew and just wouldn't engage.  And if you have a partner like that, it's the kind of partner that makes a lot of people very angry.  And Brunhilde got very, very angry and she started scratching at Spyder Cystkof, and attacking him physically, at which point he strangled her.  And to the best of our knowledge, strangled her to death, and then tossed her out their 13th story window in an attempt to make it look like a suicide.

Needless to say, the New York City Police—this took place in Manhattan—did not take a very positive view of this, and they arrested him.  He was charged with second degree murder; basically, an intentional killing without thinking about it ahead of time under aggravated circumstances.  But whatever she did was not sufficient provocation probably for the lower homicide offense of manslaughter.

Spyder Cystkopf was a wealthy man.  He was able to really tech-up his defense, and it turned out he had a subarachnoid cyst that was pressing on his left frontal cortex.  This is a cyst — most of you know this — this is a cyst that's on the underside of the middle protective layer around the brain.  He was worked up by Fred Plum's people at Cornell, and by Antonio Demasio at Iowa, so he had very good help in trying to come up with a brain-based defense.  Essentially, PET scans showed that there were metabolic imbalances in the region of the subarachnoid cyst. 

And his defense was legal insanity.  Because of the pressure on the brain and the metabolic imbalances on the left frontal cortex, where executive control is housed, as you know, the argument was he couldn't really appreciate the difference between right and wrong. 

Well, a lot of people want to stop there.  I don't, so let me give you a little bit more history about this man.  He was 64 years old.  This was 1991 at the time.  His neurologic history was this.  In 1948, he had migraine, he had had some disorientation, and he had seizure for which he had been hospitalized.  He was worked up and absolutely nothing was found.  He was discharged with the suspicion that he had a congenital cerebral aneurysm.  That was the end of his neurological history, so from 1948 to 1991, zero neurological history.  He had no psychiatric history.  He had no criminal record.  He had no prior history of violence whatsoever.

That's the case, and I'm going to be referring to it again and again as we go back to think about how we should think about it, because in many ways, it's an iconic case for the neuroscientific view of responsibility for a number of reasons.  We had clear findings here.  We had the best people looking into it.  We actually had a very good history, and we had a clear view of what happened at the time in question.  There was very little doubt about any of that.

By the way, in the Commission paper, for those of you who have read it, you know that what happened was, at the eve of trial, there was a plea agreement—all of you probably have seen "Law and Order," you know how this works in Manhattan.  They pled out to a lesser degree of homicide, voluntary manslaughter.  The Commission paper suggests because the prosecution was afraid of the potential success of the insanity defense.  I think not, I think just the opposite. 

The prosecution was ready to deal because it was going to be an expensive, difficult trial, but I think Herbert Weinstein, Spyder Cystkopf, was willing to plead guilty to what was a very serious stretch of years in prison, about seven years for at that point a 64-year-old man, because he knew he was going to get convicted of murder if he didn't plead.  And I think that's the real thing that happened.  That's certainly what the lawyers thought at the time.  By the way, he was offered at that point to have the cyst aspirated, and he refused. 

The law's concept of a person—you know, we can think of ourselves as biophysical machines, but if I were to ask any of you, any of you, including the neuroscientists in the room, why are you here today—you would not tell me a causal story about mechanisms and brains, and neurotransmitters.  You'd say something like, "I'm a member of this Commission.  I desire to be here because I desire to do good work, and it's interesting and stuff like that, and based on that desire and belief and all that, I formed the intent to come here, and that's why I'm here."

Well, the law thinks of human beings not as mechanisms.  The law thinks of human beings as I described before, as conscious, rational, intentional agents.  Now by that I don't mean that we're all perfect ratiocinators all the time, or anything of the sort.  What I mean simply by that is, if we try to explain our actions to each other, we do it in terms  essentially of what the philosophers of mind and the psychologists call the folk psychology.  The old simple practical syllogisms, desires, beliefs, and intentions.  And so we can, therefore, distinguish between three sorts of phenomena. 

Suppose we're trying to explain my arm going up.  You've all had the paper, so this is familiar to you.  One possibility is—and by hypothesis, Michael Gazzaniga is much stronger than I am, and although I'm trying to keep my arm down, he pulls it up, not my action at all.  I did not intentionally raise my arm.  But now let's change the hypothetical.

Michael pulls out a gun.  He sticks it in my head and he says Stephen, raise your arm or I'm going to blow your brains out.  Guess what?  Now is that intentional?  You bet it's intentional.  What's my desire?  To live.  What's my belief?  If I don't raise the arm, he's going to kill me.  And so I form the intention.

Now suppose something really bad was at stake if I raise my arm.  I really shouldn't have raised my arm.  You might give me an excuse, but not because I didn't intend to raise my arm.

Now the third case, I raise my arm as I did.  Now why did I do that?  I did that because I have a desire to produce a message for you folks.  I believe if I do an adequate demonstration, that will help that.  And, therefore, I formed the intention to raise my arm. 

Notice my arm moves the same in all three cases.  There is a causal explanation.  I'm a materialist.  I'm not a dualist.  There's a causal explanation in all three cases, but those are three different phenomena.  And it simply is bad thinking, I think, to think that they are not different phenomena.  Just because everything has a causal explanation doesn't mean everything is the same.  That's just a mistake.

Now how does that arm go up?  Because that's the action, as it was when there was a gun to my head.  Notice, fully responsible.  No one is going to excuse me for raising my arm as part of the demonstration.  If Michael put a gun to my head, you might very well excuse me.  In the first case, when he pulls my arm up "against my will," people are going to say that's no action at all.  That's not something to be excused or not excused.  It's simply not my action.  It's, we would typically say, Michael's action.  My arm moved, but it wasn't my action.

Now how do those arms get up in the air?  Well, I love as I know I've told you, to ask neuroscientists how that happens.  Well, we know certain necessary conditions about the brain and the nervous system, and the muscular-skeletal system, that if those aren't in place it won't happen.  But let's assume it is in place, you're neurologically and musculo-skeletally intact.  How does that arm get up there?  We don't have a clue.  We don't really have a clue, and that's the most basic thing about us, our intentionality. 

And since this is a Council on Bioethics, I thought I would read to you from literature which can sometimes explain a mystery, as well as anything else.  This is from Ian McEwan's acclaimed 2002 novel, Atonement. A young woman is talking or is being described.  "Brione sat on the floor with her back to one of the tall built-in toy cupboards and fanned her face with the pages of her play.  The silence in the house was complete.  The silence hissed in her ears, and her vision was faintly distorted.  Her hands in her lap appeared unusually large, and at the same time remote, as though viewed across an immense distance.  She raised one hand and flexed its fingers, and wondered, as she had sometimes before, how this thing, this machine for gripping, this fleshy spider on the end of her arm, came to be her's, entirely at her command.  Or did it have some little life of its own?  She bent her finger and straightened it.  The mystery was in the instant before it moved, the dividing moment between not moving and moving, when her intention took effect.  It was like a wave breaking.  If she could only find herself at the crest, she thought, she might find the secret of herself, that part of her that was really in charge.  She brought her forefinger closer to her face and stared at it, urging it to move.  It remained still because she was pretending.  She was not entirely serious, and because willing it to move, or being about to move it, was not the same as actually moving it.  And when she did crook it finally, the action seemed to start in the finger itself, not in some part of her mind.  When did it know to move?  When did she know to move it?  There was no catching herself out.  It was either/or.  There was no stitching, no seam, and yet she knew that behind the smooth continuous fabric was the real self which took the decision to cease pretending, and gave the final command."

I don't think any of us can actually do better than that, although as I said, the task of neuroscience I think is to explain how that happens.

All right.  So if you think about the law's concept of the person as rational, potentially rational, intentional actors, that makes all the sense in the world.  Think what law is, and now I'm going to be really jurisprudentially potted, simple-minded.

It's a series of rules that are meant to guide behavior, that are meant to be used in our practical reasoning for deciding what we should or should not do.  That's what law is, and law can then only be addressed effectively to creatures who are able to use those guiding rules as part of their practical reasoning, as part of figuring out what they have reason to do and not to do. 

Some of the other animal species don't have — where are the chimp legislatures?  Where are the porpoise and Ms. Manners, they don't exist.  There are no rules in the sense that we have rules.  So that's the kind of creature we are for the law.  What are the responsibility conditions? 

First, what is responsibility?  It's an attribution to another human being by a human being about action.  And when I say "action", what I mean here is to give you three criteria for responsibility in law.  Basically, there has to be an action.  Secondly, you have to have—and now I'm mostly doing criminal law, because that's what I know most exercises you folks this morning.  There has to be a culpable mental state that accompanies that action.  I'll explain these in a second.  And thirdly, you have to be in general a morally responsible agent.  And the basic criterion for that is that you have the capacity for rationality. 

Let's go back to Spyder Cystkopf.  He was charged with murder.  The act that's the prohibited act is any form of killing conduct; shooting, poisoning, strangling, throwing her out the window, nunchaku, you pick it.  The law is not very specific.  Any killing action will do.  There has to be a culpable mental state.

In this particular case, he had to intend to kill her.  It had to have been his purpose to kill her.  If he causally killed her accidentally, that wouldn't be a crime, because he didn't have the culpable mental state, assuming he was entirely acting carefully and it was just pure accident.

Thirdly, he had to, in fact, be a potentially rational agent, have the capacity for rationality at the time.  That's what the insanity defense decides, because if you think about his case — did he strangle her?  Did he do that act?  Sure he did.  Did he intend to do it?  Sure he did.  Was he a rational agent at the time, was his rationality compromised by his cyst and potential cerebral metabolic problems?  Perhaps, and we'll talk about how we would understand that.

So those are your essential responsibility criteria.  You've got to act, you've got to have a culpable mental state, and you have to be the kind of creature that has the capacity for rationality. 

Now how much capacity for rationality do you have to have?  That is not self-defining, that's not something that science can tell us.  It's a normative question.  It's a moral question.  It's a political question, and ultimately, it's a legal question.  We could be tough-minded, or we could be tender-minded.  If you're tough-minded, so long as you have even a little capacity for rationality, we may say good enough.  If you're tender-minded, even a little defect may be enough to excuse you.  That's what we decide as a society, ultimately through our legislators and through our legal system.  And these things wax and wane in terms of how tough or how tender we are going to be.  So what is the major excusing condition in law?  It's lack of capacity for rationality. 

Now you can also defeat legal liability by showing you didn't act.  Suppose you could show you were in some kind of automatic state that would also defeat liability, what we call prima facie liability, because you might be able to show I didn't intend to kill a human being.  Suppose—to use a silly example, because this is not how hallucinations work, as you know, but to use a model penal code example—suppose I all of a sudden believe that Paul McHugh is a lemon, the actual citrus fruit.  And I squeeze around, strangely enough, his neck, not his leg, but I squeeze around his neck and I strangle him to death.  And now I'm charged with the intentional homicide of Paul McHugh, and I say I didn't intend to kill him at all.  I intended to squeeze a lemon.  If we believe me, I didn't intend to kill him.  Now I wouldn't believe me, but if we did, I didn't intend to kill.

And by the way, what the law means by intention is nothing fancy, nothing fancy at all.  It doesn't mean your capacity to think through and be a hyper-rational human being.  It just means did you do it on purpose?  And notice, by the way, even little kids do things on purpose.  They intend, and the reason we don't hold little kids responsible, once again, is not because they don't intend.  It's because we don't think they have the full capacity for rationality yet. 

Now there is a second question, besides the lack of capacity for rationality, that goes to responsibility; which is, gee, what about people who seem to be rational, but we say they are compelled or coerced.  So think of my second hypothetical with Michael Gazzaniga who's holding a gun to my head.  What does it mean to say I'm compelled?  Now this is really fraught.  I could spend hours on this, so I am going to give you the really short form.

It's not well understood, but notice there are two different kinds of compulsion.  If he pulls my arm, it's literal.  I didn't act.  If he sticks a gun at my head and says do it or else, the compulsion is metaphorical.  It's not literal.  I could take the bullet and not do what he wants me to do, which is to raise my arm.  It's going to be an extremely hard choice for me, and we might give me an excuse if I yield, but not because I didn't act, not because I wasn't rational.  And what I would like to suggest is what really explains compulsion, separate from the literal compulsion cases, is that we are faced with a very hard choice that we think is too hard for the ordinary human being to resist.  Not too hard in the mechanistic sense, too hard in the gee, we can't expect him to take the hit if he doesn't do it. 

Now if you think about people like addicts, people who have sexual disorders and the like, most of them fall in the metaphorical compulsion.  They don't fall in the literal.  No one forces the addict to shoot up.  No one forces the pedophile to put his hand on a child.  It may be very, very hard for the person not to.  We need to think very carefully about what it means if we say they are "compelled".  It's going to be metaphorical. 

Okay.  When we hold people responsible and we say they deserve praise and reward, or blame and punishment, we sometimes use the terminology of free will.  I wish if I could leave you with a second message, you'd stop talking that way and thinking that way.  Free will is not a criterion for responsibility in the law, despite some loose talking cases about it.  There's no legal criterion called "free will."  When we use free will talk, what we mainly mean by it is a conclusion.  We all know you can't be responsible unless you have free will, so if you say gee, that person lacked free will, what you really mean to be doing is saying to your listener, I think this person shouldn't be held responsible.

But what I say to such people is, well, tell me what it is that that person lacked?  What is this free will that you say the person didn't have?  And what I would like to suggest to you is if you look at criteria in law and morals for responsibility, where you might be inclined to use free will talk, what you're really going to be doing is saying there's some problem about rationality, or there's some problem that you want to call compulsion.

Now here's what's true about us as creatures.  We're all different.  In terms of flying straight, and "controlling ourselves", and behaving well when we have a desire not to behave well, or a temptation not to behave well, you know, for those of us who are fortunately endowed biologically, and fortunately endowed by our environments, in our child rearing, in our communities, on average it's going to be easier for us to fly straight.  We're the lucky ones.

If you're not fortunately endowed by your biology, if you have an unfortunate environment, an unfortunate community and the like, it's going to be harder for you.  But successful human life, successful  human flourishing, it's going to be impossible unless we can live safely, interdependently together.  And when it comes to criminal behavior, we're not expecting a lot of each other.  Not killing, not raping, not stealing.  This doesn't require rocket science ability.  All right.  You don't have to be a genius to figure this one out.  We all understand these things.  We don't expect a lot of each other.  It really isn't a lot to expect.

Now again it's going to be harder for some people than for others.  And when it gets to be harder because their rationality is maybe less good, because they've learned fewer techniques to help them control themselves, we're going to be more sympathetic.  But where we draw the line in deciding who's responsible is a moral question having to do with human beings as I've described them.

Now I'm going to get to the neuroscience, believe me.  But it's impossible to understand the role of the neuroscience, or any other science in thinking about human behavior without having a model in your mind of what we're doing when we're holding responsible.  So now let me add a further bit of background.

What we have in our legal system, not yet fully constitutionalized, and perhaps will never be fully constitutionalized, but the story I'm about to give you is a very good positive description of the way our law works.  We have what I call desert-disease jurisprudence.

If we think about when we can control people who are dangerous, and in a liberal society notice what we do.  We know there are lots of people—and by liberal, I don't mean either wing of either major party.  I'm talking about post-Enlightenment and liberal political philosophy, which as we know, is a very large tent.

In a liberal society, although we know there are lots of people who are dangerous out there, we do not intervene.  We let them be dangerous.  The third-time armed robber about to walk out of prison who says to the warden on his way out—of course, they never have exit interviews, but assume they did.  We've all seen the movie, Pat O'Brien, Jimmy Cagney says, "Warden, as soon as I get out, I'm going to go do another armed robbery."  He walks out the door.  There's nothing we can do.  Why?  We give people a vast amount of autonomy and liberty in our society to pursue their projects, even when we think they may be dangerous.  That's the cost of doing business in a free society.  We could be a less free society, but that's the kind of society we, at the moment, are.

When can we intervene?  If someone commits a crime and they deserve punishment, then we can intervene.  We can arrest them, we can convict them, and we can incarcerate them.  That's the desert jurisprudence.  That's one set of cases.

If on the other hand, we think that they are not responsible for themselves, let's say because they have a mental disorder and they are not rational about their violence, and it's not just the mental disorder.  It's the diminution of rationality that might produce the violence.  Then we can do things like involuntarily civilly commit them.  We don't have to wait for a crime.  We can intervene pre-emptively.  And that basically explains.

Now what that does is it takes creatures seriously, once again, as responsible creatures.  We don't intervene unless you responsibly violate the law.  If you're not responsible, we can intervene.  Now we could have a different story.  We could have what I call the good bacteria/bad bacteria story.

That is, there are biological creatures, the good bacteria in our gut that help it to flourish.  We don't do anything to invade them, they help us.  But we don't ever praise them or reward those bacteria.  And then there are the bad bacteria that cause all the unseemly illnesses of the gastrointestinal system.  Well, we capitally punish them—antibiotics.  And we don't say bad bacteria, you deserve it.

Now we could treat each other that way, good bacteria, bad bacteria.  You're beneficial to me, you're harmful to me.  I'm going to intervene if you're seemingly harmful, and I'm not going to worry about praise and blame, punishment, reward.  But we don't.  We take each other seriously as moral human beings.  So what are we talking about here?

We have to assess behavior.  We have to assess the acting human being.  We don't hold brains responsible.  We don't hold neurotransmitters responsible.  We hold people responsible, and people are conscious, acting, potentially rational human beings. 

Now how is the challenge of the neurosciences different from past challenges to this model?  Well, there are two kinds of challenges.  There are what I call the broad challenges, and the narrow challenges.  The broad challenge is an external critique.  It basically says, given what the neurosciences have to teach us, your whole set of responsibility practices, the whole deep moral, political, legal structure involved in holding responsible and responding to human beings in that way, is misguided ab initio from the get-go.  See, you don't understand, goes the critique.  We're just biophysical creatures.  Responsibility is a myth.  All right.

Now in that respect, the neurosciences as material sciences, are no different in this respect from any other previous allegedly scientific, allegedly deterministic, allegedly mechanistic explanation of human behavior.  Just fill in, as Dr. Kass did for neuroscience, psycho-dynamic explanations, genetic explanations, socioeconomic explanations.  They've all been meant to do the same placeholder work, and what it really is, is it's just the old first year college debate.  If determinism is true, is responsibility possible?  Now here's what I want to tell you.

The best answer to that i,s no one will ever be able to solve that.  There are a number of contenders out there in terms of the metaphysics of responsibility.  There is a perfectly plausible metaphysical answer for why responsibility is possible in a deterministic world.  And by responsibility, I mean real responsibility, I don't mean as-if responsibility.

We can't do that here.  I do some of that in the paper.  You've had access to the paper.  But there's nothing new about the neurosciences here.  There really is not.  The only thing the neurosciences could ever do that would change that would be to show us that, in fact, we are not conscious, rational, intentional acting agents.  Now maybe the neurosciences will show that, but they're nowhere close to showing it yet, and my belief is they're going to be showing just the opposite—how that is possible for us, not explaining it away.

The major error people make when they give a causal explanation for behavior, causal explanation from any domain of causation, from the most fundamental molecular, right up to the sociological.  Because to think if I've got a cause, I've got an explanation, I've got an excuse.  Causation is not an excuse.  If it were, no one could be responsible for anything.  It's the same deterministic misconception.

Causation is not compulsion.  In my three hypotheticals, Gazzaniga pulls my arm up, Gazzaniga puts the gun to my head, and thirdly, I raise my arm as part of the demonstration.  There's a causal explanation presumably using levels of explanation for many domains, that explains all three absolutely.  But only in the first two was I compelled, I was certainly not compelled in the third.  And the forms of compulsion were different, as we've seen, literal versus metaphorical.

So neuroscience does not provide yet an external critique, and I don't think it's likely to.  But how about more narrowly?  Here's where I think the  neurosciences actually get a lot of traction or potentially have a lot of traction.

I've said to you already that the criteria for responsibility, given the model of the person in the law that I've explained are act, mental state, the capacity for rationality.  What the neurosciences or people who want to make claims based on the neurosciences might concede is okay, I'll give you your model of the person.  I'll give you those criteria, but I can now show you that there will be cases where previously you thought people were responsible using those criteria, but now with the neurosciences I can show you they're not.  Perfectly plausible.

Let me interrupt for one second.  We started about ten to a quarter after, Dr. Kass.  Do I have 35 minutes from then?  Okay.  Any time you want me to, just go (snap), and I'll stop.

Okay.  Let's start with the very first most  fundamental criterion, that you have to have an action.  Now there's a book by a very famous psychologist from two years ago, Daniel Wegner of Harvard, called the "The Illusion of Conscious Will".  The argument simply is—and now I'm really going to simplify with apologies to Dr. Wegner, who is a very eminent psychologist—that this notion I've been running of practical syllogisms, desires, beliefs, intentions—is not true.  That sort of mental stuff isn't really doing the work.  We're really all automatons.

Well, one question I have for Dr. Wegner might be — are you telling me, Dr. Wegner, that your brain wrote that book and, therefore, you shouldn't get the royalties?  But okay, is it possible that we're all just automatons?  We're all suffering from sort of the automatic states that sometimes brain disorders or even psychological disorders can sometimes — are we all in hypoglycemic fugue states or something like that?  Well, yes, I guess it's possible, but it's not bloody likely.  And I think to believe that, you'd really have to be half-cocked at this point.  The neurosciences may show us there would be cases that we think we're acting intentionally and we're not, that you could show us that we're in more automatic states than we thought we were.  Fine.  In those particular cases, you've expanded the cases of no action.  I just don't think it's likely we're all going to be shown to be in that state all the time.

It is certainly the case that we often, most of the time, I'll even concede all the time, don't know all the causal explanations for why we behave as we do.  Of course not.  It goes back, if you're a materialist as I am, to the beginning of the universe.  Does that mean we don't act intentionally?  Well, you can act intentionally without knowing why you're doing it, not knowing all of the causal explanation.

I mean, did Herbert Weinstein when he killed his wife, whose real name was Barbara, by the way, not Brunhilde.  When he killed Barbara, did he know all the causal roots?  Of course not.  Did he intentionally strangle her to death?  Of course he did.

So what about the impulsively violent?  Well, let's think about what we mean by the "impulsively violent".  Let's be commonsensical about this.  What we mean by the impulsively violent are those people who, if you will, are steep time discounters, for whom the desire becomes the deed, who don't seem to think very carefully ahead of time.  The second they have the desire, they seem to do it.  That's what we mean by impulsive.  That's the common sense of it.  And we might very well get a very good neurophysiological explanation for why some people are seemingly characteristically impulsive, while other people might be impulsive on a given day or a given time.  Sure.

Does that mean when they act "impulsively", that they're not acting intentionally?  Not at all.  It doesn't follow.  They may not be very seemingly capable of rationality at the time.  They may not be very thoughtful, but it doesn't mean they're not acting intentionally.  That will not have been shown.

So what you're going to have to show is that these folks were in an automatic state, and that is going to be very hard to show in most cases.  Some cases sure, and the neuroscience is going to help us with that.  When people make claims that they were like in a hypoglycemic state or something, the neurosciences could help us with that.

Now what about the neurosciences and the formation of culpable mental states, like intent.  You saw in some of these cases in the briefing paper, gee, the neurosciences have shown us that a person lacked the capacity to form the intent.  In my view, most of those cases are make-weight, and they're just blowing smoke; that in fact when we say the person lacked the capacity to form the intent to do it—I mean, if someone were to tell me that about Herbert Weinstein, I'd say the facts absolutely belie it.  Of course he intended to kill her.  To tell me he didn't have the intent, capacity to form the intent, is simply to be confused. 

In most cases of human action where you've got actual human action, people have the capacities to form these mental states.  They may, again, lack full capacity for rationality and the like, but it's not because they don't intend to do what they do. 

So that brings us to where I think the neurosciences may have the most traction of all, which is to show us in what ways particular brain states, particular kinds of disorders and the like can actually affect our capacity for rationality.  But here you get something very interesting.

When you're trying to figure out something about human beings, you can have test results, but ultimately, we're not assessing brains.  We're assessing human behavior; and, therefore, what we've got to do is look at the acting human being.

Now the famous psychologist, David Wechsler, the founder of the Intelligence Scale, said this: "When there is a difference between a person's intelligence seemingly that you would infer from their behavior and what their IQ score is"—and IQ, by the way, is a very robust measure or a good measure—"always believe the behavior."  And so what I would say about Herbert Weinstein is, okay, he had brain pathology, certainly both structural and physiological, wet and dry. 

On the other hand, if you look at all his behavior, there's nothing to suggest that this is a man who generally lacked the capacity for rationality.  Might he have been a little bit less impulsive?  Might he have been a little bit more together if he hadn't had the brain pathology?  Sure, but there's always an explanation.  We all differ.  Does it mean he was not responsible?  Not necessarily. 

You're going to have to tell me a story, and the brain isn't going to be the whole story.  We're going to have to look at the behavior, so think about John Hinckley, and the question is not whether his sulci were abnormal or not, which was the claim.  The question was did he delusionally believe that Jodie Foster was going to run off with him or not, or did he just in his own twisted way want to have his moment of fame?  And that's the way you think about that case, and these are inferences.

Now what about punishment and things like parole?  A lot here depends on what your theory of punishment is.  Suppose you think that you could make somebody who you thought was responsible—in other words, you've done this whole analysis as I've suggested, and you thought you could make them a lot less dangerous, and a lot more rational by treating them.  Would you necessarily give them less punishment?  Well, if you think people should get what they deserve, and you thought the person deserved the full punishment, you wouldn't.  You might offer it to them in a humanitarian way, but you wouldn't necessarily reduce their sentence.

Suppose, however, you're a mixed theorist.  You also want to save the state money, give people a break if you can.  Well sure, if you thought they were safe to be abroad if you could put conditions on parole you might treat them.  You might do it.  You might offer it as a condition for parole.

A lot here depends on your moral and political theory of what criminal justice is supposed to do.  About that, neuroscience and any other science must fall silent.  This is a moral, a social, and a political judgment.  Should people fully get what they deserve, or should they get less if we think we can make them safe?  It's not a scientific question.  Neuroscience can give us the tools, but it can't answer that moral question for us.

Now I want to add one thing to this frothy brew.  You largely put the commission to me in terms of criminal justice.  But as I've described before in my desert-disease jurisprudence, there's an entirely separate form of social control from criminal justice, which is the civil commitment system. 

Now let me bring to your attention, as some of you may be aware already, something that has happened starting in 1990.  About 20 states in the union have now instituted, starting around 1990, what are known as mentally abnormal sexually violent predator civil commitments.  This is not criminal justice.  This is not punishment for crime.

The notion here is, at the end of a prison term for which someone has done time after being properly convicted as a responsible sexual offender, so properly punished because responsible, these states, fearing letting these folks go, have instituted these forms of civil commitment.  And the  Supreme Court in two cases, a case called Hendricks from Kansas in 1997, and Crane, also from Kansas in 2002, has held these forms of involuntary civil commitment constitutional.  And the reason they've done so is because they say these folks can't control themselves.  That's the non-responsibility condition.  That's what justifies civil commitment, as opposed to punishment.

Now the first thing I'd point out about that is — notice the contradiction.  These people have been responsible enough to be punished.  The worst, most afflictive thing our society can do to somebody, but now they're not responsible enough to be at liberty.  I mean, it seems to me you can't have it both ways, and how did the Supreme Court manage to do that?  I won't do that here.  But notice here, you've got a non-responsibility justification, the lack of control.

Could neuroscience help us understand the difficulties people have in controlling themselves?  Sure it could.  How much control you'd have to have to be responsible or non-responsible, that would be a moral question. 

The neurosciences may be able to help us with predictions of danger.  To the extent we need to predict, any form of science could help us with that conceivably.  Now how good would the science have to be?  The Supreme Court is very, very permissive as a constitutional matter.  Let me just give you one example.  I'm getting near the end now, Dr. Kass.

Barefoot against Estelle, the question in Texas this—for capital punishment, dangerousness was an aggravating factor such that if the jury found dangerousness, you could put someone to death.  The state's evidence of dangerousness was a clinical judgment by a psychiatrist based on hypothetical questions.  He hadn't even examined Mr. Barefoot about whether he'd be dangerous or not.  The argument was, it was an unconstitutional violation of due process to put somebody to death based on such weak evidence of future dangerousness, a clinical judgment.  And as you probably are all aware, clinical predictions are very, very weak.  A statistical prediction is better.  No one is very good on low base-rate events at the moment.  The Supreme Court said no, admissible.  It's just a matter of the weight of the evidence, not admissibility. 

Good neuroscience, even if it's not highly predictive, at least good neuroscience, it's going to all come in sooner or later.  The question about prediction is the same as the question for any other in law for neuroscience: is the neuroscience relevant?  Can you really show answers to the legal question we wanted to answer?  And what I'm suggesting is for most of the criteria I've been talking about, the answer is no. 

For prediction, it may help.  I mean, we might be able to show correlationally that certain brain events are associated with a future risk of violence, and that might help us. 

Then, of course, for these involuntary commitments—remember, this is not criminal punishment.  If we can fix people, then they need to be released, because then they're not non-responsible any more.  And the neurosciences might very well help us to figure out how to help people with problems about violence, including sexual violence.

Okay.  Let's turn in conclusion to Spyder Cystkopf once again with all this in mind.  And this is just a review of what we've been talking about so far.  Was it human action on his part or was he in some sort of automatic state?  We don't know that.  We can interview him, and he can tell us about what was going on, and he did.  And what did he tell us?  He got angry and he lunged at her, and he grabbed her by the throat and he strangled her to death.

Now was he operating with his full cool rationality intact at the moment?  Of course not.  But so do people who get angry without having anything wrong with their brains, and no one, I hope, is going to argue that anytime people get angry there's something wrong with their brains.

So anger, of course, diminishes rationality, whether that anger is produced by a brain problem, by the kind of child-rearing you've had, or whatever other reason, but he certainly acted, and he acted intentionally.

Now we all get angry, and sometimes when we're angry we want to hurt people.  Simply because his anger was caused by, let's assume in part, a diminution in control function having to do with his metabolic imbalances and the pressure on his cortex generally, does that mean he's different from anyone else who has a "anger problem", let's say produced by child-rearing?ot necessarily, and how much diminution in rationality would there have to be to hold you non-responsible?  So what I want to say is I want to look at Herbert Weinstein/Spyder Cystkopf's whole history, and I see nothing in his history that suggests to me that he has a significant diminished rationality problem.

Now what you might want to say is, well, gee, the switch flipped at that very instant.  His brain was doing just fine, thank you very much, and it's almost like a heart attack.  Finally it closed up and he had his brain freeze.  We don't have that kind of evidence yet.  There's no reason to believe that.

Spyder Cystkopf lost it.  If he hadn't had the brain stuff, would he have been a different person and maybe not have lost it?  Sure.  If you had different parents, you'd be a different kind of person from who you are, and maybe you wouldn't lose it.  If you'd been brought up in a nurturing community maybe you would be a different kind of person, and you wouldn't lose it.  Whereas, if you were brought up in a non-nurturing community, maybe you would lose it.

Now what should we do with Spyder Cystkopf?  Last point.  Well, he got seven years.  If you're a retributivist, you believe people should get what they deserve.  And that's what you think he deserves, he gets seven years, even if we could have reduced the tumor by aspirating it, and that would have made him somehow less impulsive, less dangerous.  He's probably not dangerous again.  We could probably let him out now.  If all you're concerned with is social safety, we could let him out now. Again, those are moral questions, those are political questions, and ultimately, those are legal questions.  End of sermon.

CHAIRMAN KASS: Thank you very much.  One of our Council Members has actually had a long and distinguished career touching on these questions.  In fact his little book, Moral Judgment, I recommend to all of you.  I've asked Jim Wilson to open up the discussion with comment.

PROF. WILSON:  Thank you, Steve.  That was an extremely interesting and informative, and intelligent review.   Let me ask you two sets of questions, one drawing from your knowledge of psychology, and the other drawing from your knowledge of the law.

Suppose my friend, Leon Kass, is driving a car on a crowded highway.  And suppose, and this is implausible but bear with me for a moment, that he does not know that he is subject to grande mal epileptic seizures.  Suppose if he did know it and was driving a car nonetheless, he would be arrested for reckless endangerment, in my view, but he doesn't know it.  He seizes up, the car wheel turns and he injures or kills a pedestrian.

The law would have a way of handling this.  Are there other mental states that would produce what I think exists in this case; namely, the absence of rational choice?

DR. MORSE:  I would describe the case somewhat differently.  By the way, you've got the law exactly right.  If he knew he was subject to grande mal seizures and he was driving without taking his medication or without legal permission then, in fact, if you think about it, his culpable act was getting in the car and driving.

PROF. WILSON:  Right.  Exactly.

DR. MORSE:  But let's assume he had no idea this was coming, no history, no reason to know it whatsoever, so he's acting as a human being entirely blamelessly, as we would expect of each other as moral human beings.  What I would say was wrong was not that he lacked rational choice.  I would say he didn't act at all.  I would say when that car went up on the sidewalk and killed people or whatever, he wasn't acting, because it was not conscious intentional behavior on his part.  And that would block liability at the act level, and that's the way it would be handled in every state in the union.

Now what we would do with him at that point varies from state to state.  Some places, he conceivably could be committed for treatment, but mostly what we would do with someone like that is just say from now on you take your meds and you can't drive.   Now could states like that be caused by other things?

Here's an example of how it could be caused normally.  Maybe some of you have had this experience.  You're driving on the highway and you've gone about 10 miles, and all of a sudden you say where did those 10 miles go?  You've been on automatic pilot, what we call highway hypnosis. 

Now suppose while you're in highway hypnosis and seemingly driving very carefully at the time, you ran into somebody, would you have a defense?  And the answer there would be no.  Why?  Because you were capable always of paying careful attention, not going into the state of highway hypnosis, and it's your duty as a citizen not to let that happen to you.  Now luckily when it happens to most of us, we manage to do very well and it doesn't happen.

Now you could be in that state because of hypoglycemia.  There are cases of this where people are in hypoglycemic states and do wicked things.  If they don't know about this ahead of time is a possibility, then it's exactly your case again.  If they know about it ahead of time, it's their responsibility to make sure they don't get into those states.  So that's the short answer, and neurosciences may show us that there are a wider range of conditions that would produce states like that.  If that is the case, that's going to block the ascription of action from the get-go.

PROF. WILSON:  My second question has to do with the law.  Carter Snead, who is General Counsel to this Committee, has prepared a long list of cases, and in my book I prepared a long list, and your testimony contains other cases.  And as I look through these cases, I would say that in well over half of them the effort to introduce neuroscientific evidence to reduce what they regard as the concept of responsibility has failed; the judge hasn't admitted it, or the jury heard it and did not believe it.

In maybe a quarter of the cases, it has according to the written evidence succeeded, and in the other quarter of the cases, it's too hard to tell.  But even though it's only succeeded in a quarter of the cases, we have thousands of such cases every year.  What, in your view, could be done by legislatures or others to establish clear barriers to the improper introduction of neuroscientific evidence that might misleadingly guide the jury or the judge?

DR. MORSE:  That's a wonderful question.  The first thing judges ought to do is do their job, which in my view, sometimes they do not; which is always to ask, even if the scientific evidence or the clinical evidence is good science, or good clinical evidence, does it answer the question we are asking?  They need to ask the relevance question.  And too often, they don't.  Too often they simply accept a doctor saying well, I can tell you from this bit of evidence that something is true about intent, or something is true about rationality; when, in fact, they can't.  And what I think needs to be done, is there needs to be a lot of hearings outside the hearing of a jury where the judge really pursues the evidence question carefully and says to the proponent of the evidence, you need to show me precisely how that evidence is relevant.  And that often will be extremely hard to do.

Let me give you a case from my own experience.  This was a case where a fellow claimed both that he didn't intend to kill, and that he was legally insane even if he did intend to kill.  Five psychiatrists had said that he lacked the capacity to  form the intent to kill.  Here is the story.

He said that he—and his story changed slightly—he either heard the Lord's voice, or he saw the Lord's light, and he knew that the Lord wanted him to put these two people he killed out of their misery, so he took his knife out of his pocket and he slit their throats, both of them. 

Now five psychiatrists said he lacked the capacity to kill.  It is perfectly plausible to believe that we might be able to show today—we couldn't have when this case occurred—with good neuroscience evidence that maybe he suffered from some abnormalities. 

Given those facts as I have just put them to you, could it conceivably be relevant to the question of intent, whatever the brain stuff showed?  No.  Think about why.  Why did he kill those people?  He wanted to put them out of their misery, and that's what caused him to form the intent to kill. 

I was an expert witness in that case.  As I said to the jury, what was it, an accident when he took out his knife and went and slit their throats to put them out of their misery?  Of course not.  It was intentional human action.

The courts and the legislatures have already done what needs to be done, because there is a relevance requirement.  The problem is that the lawyers and the judges need to hold the legal system's feet to the fire to make sure the relevance is shown.  That's what needs to be done.  And in cases where the facts are so clearly contradicting the alleged report of the evidence, or where the proponents of the evidence can't show the clear relation, it ought not to be admitted, even if it's good clinical stuff, even if it's good neuroscience. 

CHAIRMAN KASS: Ben Carson.

DR. CARSON:  Yes, just one question.  What role does subsequent action after having committed the act play in the whole judgment?  For instance, in the case of Spyder, after he killed her, he threw her off the balcony to make it look like suicide.  Obviously, he knew it was wrong.

DR. MORSE:  Yes.  Subsequent behavior, I believe, should be used just like previous behavior.  It helps us make an inference about what the person's mental states were at the time.  Now, obviously, a person's mental state could be unique.  In other words, they could look like they had the capacity for rationality previously, and they could look like that afterwards, but for some reason there was some event that deprived them of the capacity for rationality at the time.  That's always possible. 

But the best we can do—and remember, in the law we're always going to be doing whatever evaluation we're doing after the event has occurred.  No one has got a picture of the brain at the moment of the crime, so what is always a possibility is, anything we might find out about the brain happened after, as opposed to at the moment.

Now it's perfectly possible for one reason or another in a given case we have evidence of the person's brain before, for instance, if they had been worked up for some reason, and we have evidence after, and it looks the same, so we can obviously make the inference that the brain looked the same at the time of the event itself.  But even then we couldn't be sure, so we're just making inferences.  And so again, subsequent behavior helps us.

Now this comes up in insanity defense cases all the time.  What about people who seemingly are crazy after they have, in fact, done their crime?  Does it mean that they were suffering from a severe mental disorder and lacked the capacity for rationality at the time of the crime?  Well, certainly it helps us, but one thing that's possible, is the stress of, in fact, being involved in criminal behavior and being arrested and things like that, actually causes people to decompensate.  We can never be sure.  We're just drawing the inferences.  Subsequent behavior helps us in that respect, as well. 

CHAIRMAN KASS: Robby George.

PROF. GEORGE:  Stephen, thanks for that wonderful paper and perfect presentation.  I had a couple of questions that go to the issue of materialism.

In your analysis here in the paper and this morning, and in your other work, there's a very strong theme of anti-reductionism.  It came out today in the  critique of Wegner.  It was evident in your very strong statement about us holding not brains or neurotransmitters responsible, but people responsible.  So anti-reductionism does a lot of work in your analysis, and contrasts you with a number of other leading people in the field.  But both in the paper once, and then a couple of times today, you also went out of your way to stress your commitment to a belief in materialism, which doesn't seem to do much work in the  analysis.  But I gathered you make the point simply to indicate that the commitment to anti-reductionism, or the rejection of reductionism shouldn't be interpreted as meaning a rejection of materialism.

So my first question is, even though it doesn't seem to do much work in the argument here, why the commitment to materialism?  Is it a matter of a kind of faith?  Is it a postulate of neuroscience?  And if it's a postulate of neuroscience, is it something that someone has to be committed to in order to be a member of the fraternity, to be genuinely doing neuroscience?  Or is it possible that one could be a non-materialist who, nevertheless, does neuroscience, and would that mean there comes a point at which one has to be at least open to the possibility that while neuroscience takes us this far, and then it's time for some other discipline to come in?  So that's my first question.  I'll go ahead and ask the second one, unless you want me to stop there.

DR. MORSE:  No, I'd rather you stop there because I can barely do one thing before breakfast.  Okay.  What is the—let me make sure we're all on the same page here.

The materialist postulate simply says this universe is completely a matter-first universe.  It is not a mind first universe; that is, that anything we see in this universe can be explained by lawful material processes.  And everything, every last thing.

Now how can people believe that or not believe that?  I have, if you will, a sort of what is a warranted belief?  That's my epistemology.  When am I well-warranted in believing something?  When I look at the world around me, it seems to me that is the best explanation of the world I see around me.

How would we ever know that materialism is true?  We will never know that it is true, because the only way to know the way the world metaphysically really is, is to get outside the universe and look in.  Now most of us are professors, and we think we have a lot of power, but we don't have that much power.  We'll never know for sure, so what are we warranted in believing?  And I think materialism is the best explanation as I see it.

Now do you have to believe in materialism to be a good working neuroscientist?  And I think the answer is yes, but not all the way; and here's why.  I find this particular stance I'm about to take a little bit hard to understand, but it's not mine, but I fully appreciate it, as it were.  One could take the position that this was a mind-first universe, that there was a creator that started a bunch of physical processes going.  You could take that position. 

Once those processes were going, they operated according to particular laws, et cetera, et cetera.  But unless that mind-first decided to interfere, it was just all going to work lawfully as that mind had originally set it up.  Well, if you believe that, I suppose you could be a neuroscientist and not be thoroughly a materialist, but then you're good enough for government work materialists because unless you believe the creator or that mind is intervening, it's as good as materialism.

Now let me say one more word about materialism, and I'll take your second question.  And I've got a little riff on this in the paper.  Suppose you were convinced, as the reductionists are, that you could do an absolute one-on-one reduction of mental states to brain states, that mental states were nothing other than brain states.  And let's go all the way and be eliminative materialists; that is, that not only are brain states and mental states the same, that's pure materialism, but that our mental states are not as they seem to us, they do no work whatsoever.  We don't even really have them, we're somehow deluded or something of the sort.  Let's assume you believe that, and you came fully to believe that based on the best science.  What do you do now?

The way I do this in my classes is this; I sit on the table, and I sit very, very quietly and I don't move.  I try not even to blink.  And finally after I let that go on until the students get anxious, I say to them now, you're wondering what I was doing.  I was waiting for my neurotransmitters to fire to tell me what to do.

What are you going to do now?  What kind of world do you want to have?   Do you want to have Communism or do you want to have Capitalism?  No, do neurotransmitters tell you the answer to that question?  I don't think so.  Rob, you had a second question.

PROF. GEORGE:  Now to narrow it down a bit also on the question of materialism, now narrow the discussion to the analysis of consciousness, and even more specifically, intention, and even to the explanation of intention.

At one point, you contrasted your own thought—I'm sorry, you contrast in your own thought here between materialism and what's not materialism.  Well, it's dualism.  And I'm wondering if you are treating as exhaustive the options of materialism as you've just explained it, and dualism where dualism is explained as the idea that human beings are ghosts in machines.

Now if those are the options, then there's a very interesting question about what you do with what has always at least put itself forward as the third alternative.  We might call it the AAA alternative, because it's the tradition that extends from Aristotle though Aquinas, and its modern form, in Anscombe in her famous book, a 1958 book on intention where materialism is certainly rejected, but so is the Cartesian conception of the self as a ghost in the machine.  What do you make of the third option?

DR. MORSE:  Well, again, we don't know the answers to these questions.  There are contenders for each one of these positions, and very, very smart contenders for each one of these positions.  I'm a third way person myself, although I wouldn't ally myself precisely with Elizabeth Anscombe. 

I mean, the way I now talk about this is we have what I call a mind-brain.  I believe that our mental states are as they seem to us.  I believe they have causal efficacy.  I believe they cannot be explained except materially.  How this actually happens, we don't have a clue.  I don't think there is an immaterial ghost in the machine that somehow, as Descartes thought, somehow makes contact with the material world.  That just metaphysically seems to me to be a non-starter, although there are still people who argue for it.  So since I'm not a pure reductionist, because it doesn't seem to be the best explanation, I'm a third way person, as well—a AAA person, as well.

I don't have an explanation for you.  No one does.  It seems to me, as I've said, the task of the neurosciences is going to be precisely to explain why the third way is right, and not material, you know, pure reductive materialism.  Materialism, yes—reductive materialism, no.

PROF. GEORGE:  Thanks, Steve.

DR. KRAUHAMMER:  Leon, could I just follow up with a question on that?

CHAIRMAN KASS: The President's Council on Metaphysics is going to continue down this road.  Yes, Charles, please. 

DR. KRAUTHAMMER:  Well, I'm sorry.  I was provoked.  If you don't believe in the ghost in the machine explanation and there's a third way, wouldn't that third way involve you sitting at the end of your chair and waiting for the neurotransmitters to kick in?

DR. MORSE:  No, I don't think so because we are creatures—I mean, when I ask why are we seemingly at the moment top dogs on this planet?  Now we may blow ourselves up, of course, and no longer be top dogs, but why are we for the moment top dogs?  Are we the fastest?  Are we the strongest?  Do we have the longest teeth, the sharpest claws?  And the answer is no.  What do we have?  We have our rationality.  That has been our comparative advantage.  That's why there are so many of us, and why seemingly, if you believe this, we're doing so well.

I can't wait for the neurotransmitters to fire because the kind of creature—and I think there's a perfectly plausible evolutionary story for why this should be so—because the kind of creature I am is the kind of creature that must deliberate.  Now here's why that must be so.

First, we are the sorts of creatures that care about what happens to us.  I won't deliberate if I don't care.  Virtually everyone cares about what happens to them, even if only at the most basic level of pleasure/pain.  You don't want to have pain.  How do you avoid pain?  Not by sitting there and waiting for your neurotransmitters to fire.  It's by living your life in a way that maximizes the possibility that you won't have pain.  And here's what I also know, if I know anything.

I know that my desires, beliefs, and intentions make a difference in this world.  And I can't wait simply for my neurotransmitters to fire.  I've got to deliberate, and I will.  And that's the kind of creature I am.  And once again, I'm waiting for the neuroscientists to explain to me how that happens, which I believe is possible they will.

Now a lot of, as those of you who are philosophers or have a background, know, there are a lot of philosophers who think as a conceptual matter, we'll never be able to solve that.  I'm totally open-minded about that.  I think we will be able to solve it, but not yet.

CHAIRMAN KASS: Gil Meilaender.

PROF. MEILAENDER:  I thought the presentation was very helpful and useful, and so I don't really want to question it exactly, but just explore something with you.

Once I had to take the Minnesota Multiphasic Personality Inventory, and was amused to find a question recurring at various points along the way about whether when I walk down the street I heard voices telling me what to do. 

Now if somebody told us that they heard voices sometimes telling them what to do, would you think it was at least possible, or perhaps likely, that they lacked the capacity for rationality?  I'm going to follow up then, but I'm trying to get clear here.  That would be just a behavioral kind of—

DR. MORSE:  Sure.  And in fact, if you look at the diagnostic criterion throughout DSM-IV-TR, they're virtually all behavioral, by which I mean perceptions, thoughts, beliefs, feelings, actions.  DSM-IV criteria are not about brains and nervous systems.  So now we have somebody who has—and let's assume—an auditory hallucination, and they hear voices telling them what to do.  Well, clearly they're out of contact with reality.  That is a major rationality defect.  The question then would be, are they responsible for behavior they do, depending on what the voices tell them to do, and that's a very interesting moral question. 

Suppose what the voices tell them to do is something that is obviously wrong versus obviously right.  Suppose the voices tell them give alms to the poor, versus the voices tell them kill the first unoffending stranger you see coming up in the street.  All right.  Let's just take that case, because if you just give alms to the poor, they're going to take them.  They're not going to say I don't want your money if the voices told you.  They're going to take them, and no one is going to question you.  So now we have the case where you've killed somebody, and you say why did you kill that person?  And you say well, the voices told me to do it.  The case comes up all the time, actually.  Often enough the voice is the voice of God, and that raises even more interesting moral questions, but let's take it as a non-God voice that tells you to kill.

Some people would say you lack the capacity to make a rational judgment because part of your reasons for action are based on some kind of abnormality you have that is out of touch with reality.  That is one plausible moral response to the case, and some people take that view.

Here's another plausible moral response to that case.  You had a reason that was out of touch with reality, but you knew what you were doing.  You knew you were killing a human being.  You knew that was wrong to do both morally and legally and, therefore, you shouldn't have done it, even if it was caused in part by an abnormality.  Now notice we're all accepting the same facts.  We just have two plausibly different moral responses to that case.

PROF. MEILAENDER:  But here's what I want to know.  Let's suppose that some of us think that it is a fairly good reason for thinking that we shouldn't hold them responsible in the same way.  I'm not saying I do, but let's just hypothesize that which you granted was one way that some people would think about it, but you don't necessarily find it persuasive.

Now suppose we found in the future that something connected in the brain was very strongly correlated with hearing voices to tell you do something.  And we asked Spyder, whoever had done something did you hear the voices again this time?  He says well, I really can't remember anything.  I don't know.  But we know from studying him that he's got this condition that is very strongly correlated with that.

If we're those people who tend to think that this is a reason for thinking you have a very diminished capacity for rationality, would we now have a reason kind of excusing condition in place even in the absence of any report of the behavioral manifestation?

DR. MORSE:  First, let's go back to your initial question.  If someone says they want this to be an excusing condition, that you heard voices and those were part of your reasons for action, we need to find out what is the excusing condition.  What is your theory of excuse that leads you to use that?

Now what sometimes people will say is, well, gee, if people act in response to voices, they can't help themselves.  And then I want to say well, what do you mean by that?  And they need to explain that to us. 

Let's assume that people could come up with a coherent moral theory for why we should excuse.  Let's assume we could do that.  They didn't just wave their hand and say well, people can't help themselves when they hear voices, because that is simply question begging, so you need to come up with a really good moral theory.

Let's assume you've got one.  And as I said, I think there is a plausible one.  Now you've got the case you put to us where the person is unable to report the behavioral phenomena that might bear on that question, but we have good neuroscientific evidence to suggest that it is very possible that the person was suffering.  Well, let's think about that for a second.  Let's think about what the neuroscience evidence would have to look like.

If you've got the neurological correlate, does that mean you're always hearing the voices, sometimes hearing the voices, hearing the voices 40 percent of the time?  How strong is that correlation?  How sure can we be from finding that neurophysiological finding that people with that finding, almost certainly from everything we know about the way the brain and behavior works, is people could have behaviors without a particular brain correlate, and vice versa.  It's not going to be a necessary and sufficient condition.  It's going to be predisposing.

So the question would be what percentage of people actually have it?  Among those who actually have the voices, what percentage of the time do they hear them?  And what I'm suggesting to you is, depending on the neuroscience, what the statistics look like, we might be quite sure that the person was probably hearing voices at the moment, versus gee, it's really pretty improbable that they were hearing the voices at the moment, even if they've got the correlational finding, so that's the way I would approach that case.

CHAIRMAN KASS: Actually, I was next in the queue  and it follows Gil's comment.  I'm very sympathetic to  the thought behind the presentation and the presentation, but I also think you may have made things somewhat easy for yourself, so I would like to try to make it more difficult.

I mean, the case you cited and which you referred to often is the man who has no previous history of similar sorts of things.  But in response to Jim Wilson's question about epilepsy, you acknowledged that there might be brain-based grounds for recurrent behavior, which you say would, in a way, not be action because the person was having a fit and was possessed by something, or in the grip of something.

It does seem to me that there might be comparable kinds of fits that don't manifest themselves in tonic-clonic motion, but manifest themselves in a kind of explosive rage.  And that never mind whether somebody who knew he had this becomes somehow more culpable by not taking his medication.  But simply speaking sort of neurophysiologically, we might come to understand that  there are brain storms or fits that get a hold of people, and in which the kind of case you've cited isn't somehow a proper precedent.  That would be the first point.

Second, take the example of the sexual predators for whom there is now increasing tendency to regard these people as—whatever you think of their moral responsibility, we think we can treat them pharmacologically, and we make certain kinds of treatment a condition of their parole.  To the extent to which one comes to see that intervening medication can affect the impulse, might we not come to reconsider the question of their ability to be able to control themselves in the first place?

In other words, I think there are various things afoot here which would lead one to wonder about the confidence that we can continue to have in the traditional way of understanding these matters.  And a final point, which really goes to the business about rationality.

The Model Penal Code developed by the American Law Institute has this formulation.  "A person is not responsible for criminal conduct if at the time of such conduct, not at other times, but at the time of such conduct, as a result of mental disease or defect he lacks substantial capacity (a), to either appreciate the criminality of his conduct, or (b), to conform his conduct to the requirements of law."

The second doesn't look to me as if it was simply a matter of rationality.  It might be that one simply cannot at that particular time, owing to some abnormality of the brain, be capable at that particular juncture of conforming ones conduct to the matter of law. 

All of those things suggest to me that we might be on the threshold of seeing a whole bunch of new things, which would affect the way we think about this.  Never mind the question now of guilt or innocence exactly as a legal requirement, but simply how we would understand this behavior; and, therefore, how we would come to judge it and treat the people subsequently.

DR. MORSE:  Okay.  I actually think questions two and three are very much the same question, so I'll structure my answer accordingly. 

The brain storm case, the person who's in impulsive rage.  He's standing at a bar, somebody looks at him cross-wise, and the next thing you know he takes his beer bottle, he breaks it and he sticks it in someone's throat just like that.  Might we be able to show with the neuroscience that at least some people who react that way to perceive slights, whatever provocations, whatever you want to call them, that at least some people like that are seemingly incapable of bringing reason to bear, seemingly incapable of bringing whatever are the self-control techniques we all use to bear, is it possible that neuroscience will show us that some people really don't have the right stuff?  Sure.  But I would be very, very surprised if it were the case that everyone who reacts in anger, impulsively, were to be shown to be suffering from that same defect.  Some yes, some no, and for those for whom the answer is they have the defect and it really does seem to "compromise" their executive function and the like, we might very well think that they suffer from diminished rationality, or perhaps not from rationality at all and ought to be excused.

Now notice how you'd respond to those people is very interesting. If you know you're like that, maybe you better not go to bars.  And the thing about yourself that you know is, you have a history as a human being.  You know, if it's happened to you before, you better do whatever it takes.  If you're a loose cannon on the deck, maybe you better lock yourself up in a cork room.  And if you don't lock yourself up in a cork room, maybe we as a society have a right to, in a sense, confine you. 

And by the same token, this is like Jim Wilson's question, you know you're like that.  Maybe you are responsible, maybe not at the moment.  It's what philosophers sometimes refer to as synchronous responsibility.  At that moment you're not, but by putting yourself in harm's way, you were responsible.  You shouldn't have gotten in that car and driven knowing you have epilepsy, so finding this out would not answer our question about responsibility.

Now what about this treatability question?  Dr. Kass is absolutely right.  Every time we find that with some therapeutic technique—and notice, by the way, it doesn't have to be chemical—it could be a psychological technique, it could be a sociological technique—that we are able to reduce a person's risk of behaving in a particular way, we tend to think immediately mechanism is at work, and the person wasn't responsible.  But that, in fact, is simply a conceptual fallacy. 

We tend to think that way, is it true, but that's a danger.  Just because there are causal explanations for why you did what you did, and if we change the causal chain, you would have behaved differently, does not mean you were not a rational actor at the time. 

Now again, we may want to let people out early.  We may want to put conditions of control on and stuff like that because this is a sensible way of using scarce social resources, but it might suggest nothing about the responsibility for action at the time.

Now what about these folks who can't control themselves, the sexual offenders—this is really hard to understand.  And I confess to having the same difficulties, and Dr. Kass and I were discussing this just prior to the meeting, as well.  Let's take LeRoy Hendricks, the first Supreme Court case, who is basically going to spend the rest of his life in jail, who had a lifelong history of molesting small children.

Interestingly, enough by the way, he didn't rape them.  It was more of the sort of "taking advantage of", but he was doing it.  And what he would way is, especially when I get stressed, I just can't help myself. I can't control myself, and the only thing that's going to cure it is death. 

Well, let's ask ourselves the following question.  Suppose I was walking around with LeRoy Hendricks, and let's assume he wants to live, and that seems to be not a very strong assumption.  It's a weak assumption.  And I'm walking around with him, and I hold a gun to his head and I say, Mr. Hendricks, if you touch a child, I'm going to blow your brains out.  Now is he going to touch a child?  I don't think so.  So we're not talking about literal compulsion.  We're talking here about metaphorical compulsion.

Now he says to us it's very, very hard for me not to.  Let's think about what he means by that, just phenomenologically.  He doesn't mean gee, I don't want to touch a kid, but someone takes my hand and puts it on a kid.  What he means is, my desire builds up.  It gets stronger.  You have a desire for things.  You get really, really hungry, you really desire sex too sometimes, whatever it is.  My desire builds up.  Unfortunately, I have been dealt a very bad hand in life.  I want something that society says I can't have, and so I'm in a really tough spot.  So my desire builds, and my desire builds, and my desire builds. 

Now is there another desire unit where all of a sudden the switch is flipped, and all of a sudden this hand jumps out?  No.  He's an intentional human agent.  Now how does he get into that state? Why does he have these intense desires, and why for kids?  Well, maybe neuroscience can help us out with that some day, and we could even figure out ways to help him control that.  Maybe we can just by giving him an injection, or by giving him cognitive therapy, or whatever else it might be.

But when he does it, how do I explain that case?  Not that he becomes an Automaton.  Here's what happens.  This is my current best explanation, and it's just provisional.  And most of us have had this experience.  When the desire builds, and builds, and builds for something you want desperately, at a certain point, some of you may have been smokers, you can't think about anything else.  It's just a buzzing in your ear, a song you can't get out of your head.  And when that happens, it becomes very hard to think about the good, moral, and prudential reasons why maybe you ought not to do that.  All you can think about is doing it.  And so the way I conceptualize these cases is they produce a rationality problem.

Now does this mean that he's not responsible?  Well, it's a little bit again, like Jim Wilson's case, or like the case of the person with impulsive rage—LeRoy Hendricks was 52-years old.  He knew he did this.  My friend, you've got to do whatever it takes to take yourself out of harm's way, because here's what's true about him.

When he's in the refractory phase, when he's quiescent, which is most of the time, he knows he's going to do this.  He knows it's wrong.  He knows he shouldn't, and then it's his responsibility, in my view—now I'm talking my morals.  It's his responsibility as a human being, it's what he owes all of us and our children.  You take yourself out of harm's way, buddy.  And if you can't, we're entitled to punish you as harshly as the law deserves.

CHAIRMAN KASS: I still have a—the queue is long.  I'm going to ask some people to wait until the next, but we've got Peter and Michael now, and Diana and Bill, I'm going to ask you to hold your comments.  The conversation will continue after Dr. Coccaro's presentation.   Maybe Peter and Michael will ask questions together, and then Professor Morse can comment, if that's okay.

DR. LAWLER:  Sir, that wonderful answer you just gave about moral responsibility can come right out of Aristotle's Ethics.

DR. MORSE:  Absolutely.

DR. LAWLER:  And in general, when I read your article and heard your presentation, my reaction was this wise man is nothing but an Aristotelian.

DR. MORSE:  Guilty as charged. 

DR. LAWLER:  I'm going to hold you responsible.  For example, the basic thrust of your article seems to be this.  Natural science properly understood poses no real threat to the indispensable premises of our legal system.  Not only that, your general project seems to be this, to show according to nature why human beings are different, why we're rational, why we're deliberate, why we use practical syllogisms, and why we're political animals, among other things.  Right?  And so I liked your remark about where are the chimp legislators, where are the dolphin judges?  These are good questions, good questions most of your colleagues in actual rarely raise.

So going back to Professor George's point, your materialism seems to be a rather ambiguous materialism because you want to have materialism that preserves the phenomena, but at this point you only have faith that there's materialism that preserves phenomena, and it will be a heterogeneous materialism, and it's one physicists couldn't join in.  But do you think any physical explanation will ever explain why there are no chimp legislators?

DR. MORSE:  Well, you're absolutely right.  I mean, in fact, people who are religious are often fond of saying to people who are not religious whatsoever, saying well, your belief and your knowledge of the world, and the material view of the world and science is a way of getting to understand the world, is based on a faith.  I mean, you have no external evidence, external to ourselves as human beings.  You haven't stepped out of the universe.

Well, it's always sort of pretentious to quote Wittgenstein, but I will.  He says in the Philosophical Investigations, "Here I turn my spade.  You have to make certain pre-commitments with which to start."  And those pre-commitments for us are going to be based on our best understanding of the world we live in.

My best understanding, as I said, is material.  It seems to be the best explanation we're going to get.  I think in principle that the neuroscientists and the evolutionary biologists and psychologists are someday going to explain to us why human beings have legislatures and chimps don't.  But you know what, I may be wrong, and I don't know.  But that's my best explanation of that for the moment, and certainly the law follows from what I believe.  And it seems to me that in terms of a flourishing human existence, a life worth living that we care about, that this is something, a view of ourselves we don't want readily to give up.  Not yet.

CHAIRMAN KASS: Michael Sandel, an answer, and then we'll break.

PROF. SANDEL:  You've brought us the reassuring, comforting anti-reductionist news that neuroscience hasn't banished moral and legal responsibility, and apparently that it won't.  What's unclear is what the argument is for that, what the basis of this good news consists in.  And to explain why that seems unclear, and to invite you to respond, I'd like to go back to the involuntary civil commitments that you said some states had adopted after a conviction, holding people who posed a clear danger.

And this is puzzling, this practice, for two reasons; one of which you mentioned.  As you said, if we can attribute responsibility to them at the phase of punishing them, why do we not attribute sufficient responsibility to them now at the civil commitment stage?  That's one puzzling thing.

A second puzzling thing from the opposite point of view is, in so far as we want to protect society from people whom we know are predictably dangerous, why restrict the civil commitment to convicted criminals?  Suppose we could come up with ways of predicting who will be dangerous that are more reliable than the ones used for the convicted criminals.  Maybe there are other correlations that we could come up with, so it's puzzling on both of those grounds.

And you could extend the second scenario to the extreme in a way that was done in the book, and then in the movie, Minority Report.  The scenario in Minority Report is, it's a science fiction society where it's possible to predict with certainty who's going to commit a violent crime before they commit it.  And to go out and apprehend the person so that there is no crime in the society.  And the system works, and it works thanks to what they call "precogs", who are these creatures who have these prescient, predictive abilities.  They live in vats all day and somehow they figure it out, and they get the information to the law enforcement people, Tom Cruise and his friends.  And that's how it works.

Now suppose we had a Minority Report capacity to predict, not based on the precogs in the vat, but based on Gazzaniga's figuring out the brain scanning to such a degree of certainty that we could have universal brain scans and predict perfectly so that we could apprehend the would-be criminals before they commit the act.  The apprehension, the incarceration would no longer be punishment, because there would be no question of moral dessert or responsibility. It would be a kind of civil commitment replacing punishment as an institution.  That's the scenario.

Now you would be skeptical about this scenario.  You would hesitate to embrace it presumably because it would be reductionist, it would banish moral and legal responsibility.  And my question is why?  Is it on moral grounds that you want to hang on to dessert and responsibility for moral reasons, or is it on scientific grounds that you just don't think the neuroscience could ever be that good, or is it on metaphysical grounds?

DR. MORSE:  Well, that question does go to the heart of the project, and I thank you for it.  I actually didn't know about Minority Report.  In a 1995 article, I addressed just that scenario, so here's my short answer.

The kind of material predictive understanding that your hypothetical posits is so far beyond our present science addressed to the entire population, that it seems to me that to get there, we could do this, and do it for all of us without any kind of behavioral history or something of the sort, which is what we now by and large use, would be to perhaps reach the stage that Dr. McHugh talks about, where we really do now understand how the brain enables the mind, and we've reached a new level of understanding.  And here's what I think about that scenario.

When we get there, I don't know how we're going to think about each other as human beings.  I just don't know.  I think all moral, legal bets will conceivably be off.  I think it's perfectly conceivable we'll have an entirely new view of ourselves.  I mean, imagine this—would you sign on to putting yourself into a vat—suppose we could all put ourselves into a vat and hook ourselves up to the pleasure principle machine, you know, the Orgasmatron of Woody Allen—would we all do it or not?  We could decide not to do it, even though we had the capacity to do it.

We could decide, as a moral matter, either to hook ourselves up, or not hook ourselves up in Professor Sandel's example.  I don't know what we'd decide then.  I just don't know, because we're going to have an entirely different view of ourselves.  And I am perfectly open to the possibility that the neuroscience will get sophisticated enough that reductive materialism will turn out to be the best explanation, and I don't know what the debate is going to look like then, so I can't predict.

All I can do is look at the world I live in now.  In the world I live in now, purely reductive materialism does not seem to be the best metaphysical explanation of the mind-brain relation.  We certainly can do a lot of predictive work.  We still don't allow that predictive work because we do take this dessert-disease jurisprudence seriously. 

I'm glad we do.  I'm a create of my time.  I have a particular morals, a particular politics.  I don't know what my morals and politics would look like in a world that Professor Sandel envisions.  When we get there, if I'm around to look at it, we'll talk about it.

CHAIRMAN KASS: Thank you very much.  Apologies to the people in the queue.  I will get you to the front of the line.  The topic will be addressed coming from the other end.  Let me ask Council Members for a change to return promptly in ten minutes, so that we don't keep our guest waiting.  Thank you.

(Whereupon, the proceedings in the above-entitled matter went off the record at 10:50 a.m. and went back on the record at 11:09 a.m.)

SESSION 2: NEUROSCIENCE, BRAIN, and BEHAVIOR VII: UNDERSTANDING AGGRESSIVE BEHAVIOR THROUGH NEUROSCIENCE

CHAIRMAN KASS: We turn from a session on neuroscience and the law to a session on understanding aggressive behavior through neuroscience. 

Without further ado, Dr. Coccaro.  Thank you.  Very much.

DR. COCCARO:  Thank you, Dr. Kass.  It's an honor to be here.

It was interesting sitting in this morning's session, because I agreed with almost everything Dr. Morse was saying.  And I'm going to present a fair amount of data about the features and neurobiology of aggressions.  Also, some data about treating impulsive aggressiveness. 

But I really come from the point of view of trying to understand these behaviors biologically and phenomenologically, in a way so we can come up with strategies for intervention.  Hopefully, those interventions would be voluntary interventions, not, you know, state-mandated interventions.

So let me start first by disclosing that I have been a consultant for a number of drug companies, have had research grants and other kinds of remunerations.  This is just sort of a general disclosure which people in my field have decided we should be making at the beginning of every presentation. 

I'm not sure that many people here have connections to drug companies, but it is important to let you know that.  Most of the work that I have done has, however, been funded by either the VA Merit Review System or the National Institutes of Mental Health.  That's where most of my research funding comes from.

So in order to start this, I think we really need to talk about what aggression is, because it's complicated, and this is one definition of aggression — I will try not to spear anybody with this laser pointer.  But it's behavior by one individual directed at another person or object, in which either verbal force or physical force is used to injure, coerce, or express anger.  And, of course, this is, as I said, very, very broad.

But it's important to realize that aggression is part of a complex triad of behavior, emotion, and cognition.  So aggression is the behavior, anger is the emotion, and hostility is the cognition.  These things all interact in ways to lead to the aggressive event.

And the order of them is up for grabs.  It may very well be that emotion is what starts this off.  That then leads to hostility and then to the behavior, but it could be the reverse.  It could be that people have hostile attributions about what other people are doing.  That then makes them angry and makes them act in an aggression fashion.

Now, there are different types of aggression, and there's various ways you can split the pie.  This is one way that I do.  One would be socially-sanctioned aggression, and, of course, this is — anybody know who this is?  This is Tom Hanks playing in Saving Private Ryan, and this is an individual who obviously had to be aggressive in the context of World War II, but was not an aggressive person in general.  And he had to be aggressive; that was his job.

Another way you can get aggressive is have a medical problem, a real medical problem.  And this is King George.  If you're wondering why I'm using movie posters it's because it's not good to use real people in these slide presentations.  So he had porphyria episodes of severe agitation and screaming and shouting and slamming doors and those kinds of things.  But it was really due to the porphyrian.  And when those episodes abated, the aggressiveness abated.

Now we get to the more interesting types of aggression, and we have premeditated aggression.  I think the classic example would be a psychopath.  This is Robert DeNiro playing a character, a very hardened criminal, in a movie called Cape Fear.  And definitely a very premeditative individual.

I'm not going to speak that much about premeditated aggression in terms of the biology, because we know very little about that. 

But this is impulsive aggression.  Anybody know who this is?  Bobby Knight.  And he could be your neighbor, actually.  And this is the kind of people that I study.  I don't study Bobby Knight, although when I was in — when I got to Chicago he still was in Indiana.  And, unfortunately, he didn't — Indiana University didn't call me up as a consultant on his case; they just fired him.  So I might have helped him.

Now, what about the types of aggression.  Premeditated aggression is goal-directed aggression.  So when it comes to the issue of culpability, there's no question here.  I mean, somebody is making a decision to do something aggressive.  It gets a little trickier when you talk about impulsive aggression.  But even I believe that impulsive aggression, which is threat-induced or frustration-induced, there will still is that split second time to form the cognition of whether this is right or wrong.

So I do not believe in general terms that impulsive aggression is something that really forgives you of the responsibility of your acts.  What I'm interested in is:  why do people act this way?  And what can we do to make them not act this way, or decrease the frequency at which they act this way?

Well, there's another way you can break this down.  It's just primary aggression and secondary aggression.  And I talked about that a little bit before, but here's just a slide to say what could be secondary aggression.  Well, as in the King George example, you have systemic and metabolic disorders.  You can also have primary diseases of the brain.

Anything that affects the brain can affect — can increase irritability, increase the risk of aggressive behavior, and several psychiatric disorders can do that.  However, what needs to be remembered is that while aggression can run across various psychiatric disorders, and a lot of people in my field, you know, want to think aggression is the same in every disorder, you can't really do it.  There's a real caution here, and that is the phenotype of aggression may not have the same pathophysiology across disorders. 

And the reason I feel very strongly about this is that even if you were to say that there's a relationship between some biological parameter and aggressiveness, the brains of individuals who are schizophrenic, manic depressive, drug — whatever, are different from each other, and the milieu is different.

And you can have a situation where, let's say in mood disorders, depression for example, where people can make suicide attempts and be aggressive, their brains are different.  There's something different about their brains.  It might be that their catecholamine system isn't working so well.  And if that system doesn't work well, all bets are off in terms of how other systems interact with behavior.

So this is an important caveat.  And while I'm a dimensionalist in terms of looking dimensionally at aggressive behavior, rather than necessarily looking at it from, you know, disease entities, you have to be cognizant of the fact that these categories, you know, do have relevance.

So if you want to talk about primary aggression, that is, to our best way of thinking, what you could call intermittent explosive disorder.  So let me define what that is.  In DSM-IV, this is what the criteria — they're not very good criteria, but this is what they are.

Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts, destruction of property — one.  Two, the degree of aggressiveness is grossly out of proportion to precipitating psychosocial stressors.  And, three, it's not better accounted for by something else, some other mental disorder, some physiological effects of substance or a general medical condition.  But the problems are really substantial.

What constitutes a serious assaultive act or destruction of property?  DSM doesn't do such a good job on that.  How many aggressive acts do you need to have to make the disorder?  What timeframe?  And what's the nature of the aggressive act?  Which I think it's really critical.

And we really focus on impulsive aggression, even in IED, because:  a) from my point of view, the premeditated aggression really is more relevant to criminal justice rather than to mental health systems.  Explosivity really suggests impulsivity, and the impulsive forms of aggression are the ones that have clear psychobiological relevance.

That doesn't mean there isn't a psychobiology to premeditated aggression, but, rather, the tendency to be premeditatively aggressive.  But it's really the impulsive forms that really have most of the science behind them at this point.

We had to develop research criteria for IED to really bring this into line with the biological work that I'll be telling you about in a few minutes.  And what we've done is we've said, "Look, you know, the way DSM sort of defines it, you have to be almost like Bruce Banner, who gets" — that's the alter ego of the Incredible Hulk — "who, you know, gets angry and he becomes this horrible monster."

That's not what most aggressive people are like.  Most aggressive people don't have huge outbursts and then in between they're perfectly fine.  Most people have big outbursts and little outbursts, and you need to be able to account for that.  So we allow for frequent or low intensity aggressive acts, as well as infrequent but high intensity aggressive acts.

We also require those aggressive acts to be impulsive in nature, which means not a whole lot of forethought going on.  That doesn't mean they can't commit any premeditated acts of aggression, but most of the acts of aggression need to be impulsive.  And, critically, there must be some distress or impairment due to the aggressive acts.  Otherwise, it's not a disorder, especially if you allow for these low frequency attacks, into the diagnostic morphology.

Am I speaking not loudly enough or too fast?  Oh, okay.  Okay.  I guess I was making the wrong attribution of your face.

Okay.  I'm going to skip through the research criteria, but that basically incorporates those ideas.  And you might ask how much IED is out there.  How much primary aggression is out there?  Because nobody really knows, and you can't actually determine it until you have these kinds of criteria.

And, fortunately, I've been involved in some studies that have looked at this.  Is something wrong?  Too much feedback?  I did a small study that just got published indicating that four percent lifetime have this problem.  And two unpublished studies that will be published sometime in the next year or two, both large studies, showed the same exact number. 

Four percent lifetime have this problem of being impulsively aggressive and getting into trouble because of it, not necessarily criminal aggression, but aggression, nevertheless, that's certainly disruptive to their lives and the people around them.  And the age of onset is early.  It begins in the pre-teen years.  It peaks in the teen years, and then drops over time.  And the age of onset date is interesting, because a lot of the times this problem occurs before the onset of other disorders that people think probably are related to the aggression.

Now let's get to the meat of the matter.  What are the underpinnings of aggression or impulsive aggression as we know them?  Well, you can look at it from a familial and a genetic environmental and biological perspective, and that's what I'm now going to do.

So if you're looking at the familiarity of IED, you're looking at how does it run in families.  And this is a study that we did a few years ago, which we are in the process of writing up.  And we looked at people who met research criteria for IED, and we looked at people who were controlled — did not have aggressive behavior. 

And we found that more than 25 percent of the relatives, first-degree relatives, had this problem.  Whereas you only had about eight percent of the controls.  We know there's lots of co-morbidity, so we wanted to see, did having histories of other kinds of problems in these IED patients relate to the family risk of aggressiveness.  And it actually didn't.

So individuals who had IED, if they had a history of suicide attempt or mood disorder or alcohol or drug, did that change the family risk?  It did not.  And having other kinds of co-morbidities in the relatives did not.  So what it meant was that if the relative had IED, the chance that they had some other disorder was something in the range of 60 to 70 percent, and that was pretty much what it was if they didn't have IED.

So what this really suggested was this is a signal that runs in families, not due to other kinds of things.  That doesn't mean other things don't interact, but there really is a signal here.

Now, what family studies tell you — this actually was a family history study, meaning we asked relatives about other relatives rather than interview the relatives themselves.  We're currently doing a family study with NIH support to actually interview all the relatives that we can.  It gets to genetics but not completely, because what runs in families could be genetic and could be simply cultural or simply environmental.

If you want to do genetics, you've got to get twin studies, and we have done some twin studies, which we are continuing to do.  This is a little twin study we did looking at the Buss-Durkee aggression scale.  We did this because the twin sample was a male sample.

And irritability on this scale is the tendency to blow up.  Verbal assault is the tendency to scream and shout.  Indirect assault is a tendency to slam doors and throw things.  And direct assault is they hit people.  And what's important to point out here is not that environment is more important than genetics, but that genetics has a role to play here.

For irritability, it's almost 40 percent  But a nice point is that as you go from the least severe forms of aggression to the more severe forms of aggression, the genetic influence increases over time.  So there's more environmental factors going on in screaming and shouting and less in indirect assault, and about equal maybe in actually physically hitting people.  Again, what we're talking about is ultimately going to be an interaction between the two. 

Now, what's interesting what the Buss-Durkee scales is they are a tendency to behave a certain way.  There's another assessment of aggression called the life history of aggression, where you actually ask people how many times they've been aggressive.  The heritability of how many times they've been aggressive is actually much lower than the heritability of the tendency to be aggressive.

And the reason for that is really the interaction between the tendency to be aggressive and actually have things in your environment provoke you to be aggressive.  So that's sort of a fine point on the genetics of aggression, which is critical I think to raise here.

Now, what about environmental factors, because, you see, these — these greenish bars here account for most of the variance.  What's going on with environment?  If you look at all the studies, the big things that come out are experience of aggression as a child, meaning being aggressed upon, witnessing aggression as a child, and parental dysfunction.

And there are a lot of people in the field who feel very strongly that the affective environment, which would be the aggression against childhood, leading to aggressive behavior, is actually mediated by a series of processes called social information processing.  And this has to do with assessing what's going on in the environment, in the immediate environment. 

And the big things that seem to be coming down the pike is that there's a reduced encoding of relevant social information, meaning that if you ask people what they're picking up from the interaction they will not give you as — if they're aggressive people, they won't give you as many cues or many clues as to what's happening, and they will also tend to be — have an increased tendency for hostile attribution.

The way these kinds of studies are done is they present kids with these socially ambiguous kinds of vignettes where it's not clear that somebody did something to the person — the other person in the vignette on purpose or not, and they ask the kid, "Why did this person, Johnny, you know, hit this other kid in the back with a ball?"  And it's ambiguous.

And the kids who have the impulsive aggressive problems, who have the history of aggression in childhood, tend to be the ones saying, "He was trying to hurt this other kid."  So there's this hostile attribution problem.

Now, one way you can assess hostile attribution in the laboratory — and we can do it in two ways, one with sort of the laboratory measure as well as a paper and pencil measure, which I'll tell you more about in a minute, is you can look at, let's say, a neutral face in the lab and ask people — they say, "What emotion is on this face?"  We don't tell them that they can pick neutral.  They have to pick something.  They have to pick one of these faces. 

And what happens is, when you look at these IEDs and you contrast it or look at the history of trauma, childhood trauma they have, there is a positive relationship between the number of times they'll call a neutral face angry and the amount of childhood trauma they have.  And this is one of the first pieces of data, and it's not a lot of data — pieces of data to suggest that this finding that has been reported in kids is also true in adults.

We've done some more work with this, and we developed direct aggression vignettes, for example, for adults, which has not been done before.  And this is an example of one of those vignettes.  Imagine that you're in a karate class competition, and you have to demonstrate your abilities to your instructor. 

You're matched up to fight with someone in the class who you do not know well.  And while you're being evaluated, your karate classmate hits you in a way other than you were taught and you are hurt.  That's pretty ambiguous.  You don't really know, you know, what that means.  And then when ask people — and, for example, we might show them this sort of, you know, physical — this sort of illustration of what happens.  You don't really know what's going on.  A person has to then tell you, you know, what really went on.

And we can ask people, well, what did they do?  How likely is it that the classmate wanted to physically hurt them or make them look bad?  And that's hostile.  How much did the classmate want to win the match?  And whether they hurt them or not — and did he do it by accident?

What we find in the IEDs, these impulsive aggressive folks, not surprisingly is that they're more likely to say that, "The person tried to hurt me or make me look bad."  A little less likely, but more likely than normal is to say, "They're just trying to win, and less likely benign."

So these folks have a hostile attributional bias that is — in adulthood that we — that other investigators have seen in children as well.  We'll get back to more the neuroscience of this or how we're trying to approach that in a few minutes.

Now, are these environmental effects mediated by biogenetic factors?  And the answer to that is probably so, because we really live in a world of environmental gene interactions.  So it's not a matter of determinism; it's a matter of probabilistic kinds of things. 

Here's a study that was published in Science by Caspi, a very exciting study, where they looked at the MAOA genotype in — these actually weren't male children at the time they got the genotype.  It was later on in early adulthood. 

But what they had way back when when these individuals were kids was they had this assessment of whether they had been maltreated, probably maltreated, or severely maltreated, and then they got the genotype data, and then they correlated it with their disposition toward violence, which is what's on the left, and whether they were convicted for a violent offense.

And what you see here is this.  You have low MAOA activity in both of these graphs on the left, and what this really meant was that these people had a genotype that prevented this enzyme in the brain from breaking down norepinephrine, serotonin, and dopamine, and on the other side, other people who had high MAOA, meaning that they were able to break these neurotransmitters down appropriately.

You really want to be in this category here.  You want to have, you know, good functioning genes.  And when you look at the people who have good functioning genes, you have this sort of linear relationship between aggressiveness and maltreatment, as we might expect, and it's not very pronounced.  You really see it in the folks with the low monoamine oxidase enzyme activity.  So there is this gene environment interaction that is extremely important, and more studies will come out to show this same kind of thing.

Now, what about specific neurobiological factors?  The big neurobiology factor where most of the data comes from is dysfunction of the central serotonin system.  And as I was saying to some people before, I started out as a serotonin kind of guy, and I've gotten a little more Catholic since, because this is all not serotonin, which, of course, was heresy back in the late 1980s.

But there's also a dysfunction of other central systems, and there are also issues about social and emotional information processing. 

Now, why is serotonin important?  Serotonin is important because those neurons, which originate in the nuclei in the membrane, project to diverse areas of the brain, including the cortex, hypothalamus, all over the place.  They even go down the spinal cord.

And so you have a system that casts a very wide net of influence over the brain, number one.  Number two, those neurons fire in a very consistent fashion, a very tonic fashion.  They pretty much fire at the rate they fire all the time.  And it's very hard to get them to change their rate.  If you put an electrode in a cat brain and you looked at the firing of a serotonin neuron and paraded a mouse in front of the cat, serotonin neurons wouldn't do anything.  If you put that in the norepinephrine part of the brain, it would fire like crazy, because norepinephrine responds to novelty.

But serotonin really are like the breaks.  They're the modulating influence in the brain, and it kind of makes sense that if they — if it doesn't work well, if it's dysfunctional in some way, it's going to release the breaks.  People are going to have bad breaks, and that seems to be what's going on.

In the late 1970s, an interesting study from the NIMH came out looking at the correlation between 5-HIAA, which is the major metabolite or breakdown product of serotonin in the brain, and a life history of aggressive behavior. 

This study was interesting because this is not what they went out to find, and the story is kind of funny because what you had was Brown being a junior investigator at the NIH was asked by his bosses to go out and get controls.  And so he went to the Naval Hospital and recruited people who he thought were controls. 

They were people who weren't drug abusers, they weren't schizophrenic, they weren't bipolar.  They weren't anything.  And he figured he had normals.  And the data comes back and his boss goes, "What's up with this data?  These values are all over the place."  And what they discovered was these really weren't normals.  They were severely personality disordered, and one of the big dimensions was aggressiveness.

And so they went back and got a way to measure aggressiveness, and sure enough they got this very nice inverse relationship between this measure of serotonin and a history of aggressive behavior.  And this is a history of a behavior, not the tendency to behave, but the actual history of acting aggressively.

They also got the relationship with suicidality, although that had been shown before.  And they postulated that there was a trivariate relationship.  So if serotonin was the coin — was the coin, then this side is serotonin, is aggressive behavior directed outward, and this side is aggressive behavior directed inward, which would be suicidal behavior.

What happened right after was an important study coming from Finland showing that it was impulsive aggressive individuals that had the low 5-HIAA finding, not the non-impulsive aggressives.  And this has been replicated in a number of other stories.

At the same time, work was looking at specific receptors in the brain, and violent suicide victims, finding that certain receptors were down and certain receptors were up.  Specifically, serotonin transporter receptors were down, and serotonin-2 receptors over here were up.  And the suggestion was this system doesn't work so well, so this system goes to compensate.

Well, there are problems actually with that interpretation, but ultimately you don't really know what the final result is, because if you've got pure compensation nothing really changes.  And that's when I entered the scene.  I started to do work looking at pharmacologic challenges, and what we did was we gave agents that specifically simulated the serotonin system in a physiologic fashion. 

You could look at a variety of outcome measures.  We looked at proactive response, because it was the best measure to use.  And when you gave this drug, you had a nice proactive response.  If you gave a placebo, you got nothing.  And how much this went up was an index of how much you activated that system.  And what we found was a very nice correlation between how much you activated the serotonin system and how aggressive, impulsive, and irritable these people tended to be.

These are personality disordered individuals — males, in particular.  And this was assaultiveness and irritability.  And this kind of finding can also be seen in the brain.  This is work done by Larry Siever, who was my mentor at the time, who has gone on and done some other work in this area, looking at a PET scan, giving this same drug — fenfluramine — and seeing where in the brain is there differential activation?

And it's really this frontal part of the brain, as I'll talk about later, that seems to be differentially subactivated in these impulsive aggressive kinds of individuals. 

Now, what's interesting about the serotonin system, it's all over the place and the findings are all over the place.  What I mean is you can find them anywhere.  Here's a study looking at platelets.  This had nothing to do with the brain, but the platelets are a model for what goes on in the brain. 

And, in fact, if you look at the serotonin transporter on the platelets, you will see the same inverse relationship between a measured serotonin function and aggressiveness.  Almost anything you look at with the serotonin system you will get this finding.

Now, okay, so serotonin is out of whack.  These are all correlational studies.  In animal studies, we can do things to manipulate serotonin and see if these things are true.  Can we do this in humans?  Yes, kind of we can do this in humans.  This is a study by a friend of mine, Don Dougherty, who took individual — relatively healthy individuals, although some of them were more aggressive than others, and gave them a thing called a tryptophan depletion challenge.

Tryptophan depletion is an interesting kind of paradigm, because what happens is you give people these amino acids, without tryptophan, their livers go, "Ooh, amino acids, it's time for me to make protein."  So they go to make protein, but there's no tryptophan that you've given them.  So they've got to pull it from the bloodstream, and they wipe out their blood tryptophan levels. 

And why is that important?  Because the brain serotonin cells need tryptophan to make serotonin.  If they're deprived that, they won't make it.  So you give the tryptophan depletion, and five hours later they are hypo-serotonergic.  And in this study what they did was they put people through a laboratory measure to sort of piss them off and see how aggressive these people would be.  And it was only the aggressive folks who actually became aggressive, more aggressive, on tryptophan depletion.

So if any of you are worried that someone is going to slip you a tryptophan depletion mickey, and you're going to do something awful like commit a crime, don't worry about it, because it only happens in individuals who are already low in their serotonin systems to begin with.

There are other neurotransmitter dysfunctions.  The catecholamine system, the vasopressin system, and the GABA system may positively predispose individuals to aggression.  Catecholamines are a little complicated.  Some measures will show positive relationships.  Some measures will show inverse relationships.  There's probably some general dysfunction there that actually will make more sense the more research we do.

Vasopressins are a very interesting peptide that in animal studies clearly shows a relationship between facilitating aggressiveness.  Oxytocin, which often is opposite, and many people —  including Tom Insel, who is the head of the NIMH, feel oxytocin is very important in affiliation, which, of course, is the reverse of aggression.  We see reverse — a reverse kind of finding, an inverse relationship.  The less oxytocin, the more aggressive.

And so let's just come back to social and emotional information processing, because what the biology does — it sets up the threshold.  There's really this balance between bad brakes and having the foot on the pedal.  And that's the sort of situation you walk into — into the interreaction with another individual.  But how you appraise that situation gets into social and emotional information processing and leads one to whether they actually commit an aggressive act at that moment in time.

So I showed you this before, but I just want to bring it back to you.  When we looked at IEDs, and we showed them this karate vignette, and we have, you know, nine other vignettes, they're more likely to say, "This person is trying to hurt me."  The normals don't say that for the most part.  I mean, they're less likely to say that.

But something else goes on with the IEDs.  Not surprisingly, they're more likely to be upset by this, because the other question we asked was, if this happened to you, how angry would you be, and how upset would you be?  And they clearly are angry and upset, which makes sense.  And how much the hostile attributions go up is how much anger — how angry they are.  There's this positive correlation.

When we do fancy statistical — actually, not so fancy statistical analysis, it actually looks like it's the emotional piece.  It looks like how angry they get is really what targets or really modulates their hostile attributional bias.  So it looks like emotion may be the critical thing.

So usually there's this correlation between the hostile attributions and the negative emotional response, but, like I said, emotion is probably even more important, because emotions really set up how you interpret what's coming at you.  And, of course, those things are bound up in neurocircuitry.

Now, the neurocircuitry that is important, areas that are important in emotional regulation and impulsive aggression are the ones that are lit up in colors.  The big ones really are green, which is orbital-frontal, and red, which is ventral-medial.  Dorsal lateral has a lot to do with working memory, but the real circuit are A, C, and D.

So A is the pre-frontal cortex, D is the anterior cingulate, which is sort of the way station between the cortex and the — and this is really sort of the circuit.  These are all involved to some degree, but the big circuit is really this one.  And there's probably something wrong in that circuit.  We don't exactly know where we can find that out.  We're doing very specific studies with fMRI.

But one of the first studies that was done, at least in these IEDs, was a study done by Mary Best, who was one of my graduate students when I was in Philadelphia.  This was a study published in PNS a few years ago, and we looked at these IED individuals.  And one thing that she did was she gave them a smell identification test, and why we would do that — because the neurons that are involved with identification of smell run right through the orbital frontal cortex. 

And if there was something wrong with that frontal cortex — cortical area, perhaps they would have impairment in smell identification.  And as it turns out, they do.  The IEDs cannot identify odors as well as the normal controls.  Even if you looked at only the non-smokers, you saw the same thing.  So this wasn't confounded by smoking.

More interestingly, really, was this business of facial recognition and recognition of emotions, which gets into emotional information processing.  So we showed them these pictures, and we asked them, what are these pictures of?  And the IEDs are more likely to make mistakes.  They're more likely to say a face of anger is something else; it isn't really anger.  Same thing with the disgust, and same thing with surprise.

There's something amiss.  They can't identify the faces properly.  Not in every case, but in many cases.  And like I said, they're more likely to say a neutral face is disgust or anger or something or else.

Where in the brain are these abnormalities specifically?  Well, a very important study was done by Hannah Damasio looking at the case of Phineas Gage.  This was someone who had a normal personality until a tamping iron bore through the skull and brain.  Physically recovered but later became irreverent and impulsive, a poor display of judgment.  When they reconstructed the lesion of the skull, it suggested damage to the ventral-medial and orbital prefrontal cortex.  So basically the breaking mechanism was knocked down in the system. 

Now, other studies in terms of neural imaging have also looked at these kinds of individuals.  There was a study done by Adrian Raine looking at predatory and affective murderers.  Predatory murderers are really the premeditated folks.  Affective are really the reactive, impulsive aggressive folks. 

And this is a relatively crude PET study.  In a PET study, you're really looking at glucose utilization in fairly big areas of the brain, and pretty much at rest.  And what they found was that in both sides of the brain — the prefrontal cortex — the affective murderers seemed to have a deficit much more so than the affective murderers would certainly be in the controls.

What was interesting, though, however, was when you looked at the subcortical system, which would include amygdala and those kinds of systems, both of them were a little hyperactive.  So it looked like in the affective murderers their inhibitory systems weren't working so well, but their drive systems are working pretty well, whereas in the premeditated murderers their inhibitory systems were okay, but their drive systems are a little high.

Nevertheless, this doesn't really take away responsibility.  This is just interesting data to look at.

This is a copy of some scans.  This was a healthy volunteer, showing actually very nice activation in the frontal areas of the brain.  And the murderer pretty much — blue is very low activation. And these are very pretty pictures and they've very exciting, but, you know, it's — you have to take it with a grain of salt to be honest with you, and you can't really use it on an individual basis in court or to decide what you're going to do with patients individually.

I showed you this before, this work by Larry Siever — just to bring it back — that we're seeing the same sorts of things, same areas of the brain affected, when you target the serotonin system.

This is another study by — in Larry's group — Antonio New published an article in the Journal of Psychiatry a couple of years ago looking at the anterior cingulate.  And what happens here is with the normal controls, they've got very nice activations. 

You go from the posterior part of the cingulate to the frontal, but you get the reverse sort of pattern in impulsive aggressives, suggesting there's something wrong in the anterior frontal part of the cingulate.  And that's the part of the anterior cingulate involved in emotional information processing, so there's something off with these folks.

Another very interesting study is a different kind of a PET study, and this is looking at normal controls.  And what they did was they asked people to imagine themselves in an elevator going up in a building, and they're in the elevator with their mother and two other people.  And in the first scenario they just get in the elevator and then go up, and they get off on the floor. 

In the next scenario that they imagine, they're in the elevator and one of the guys starts bothering the mother, and they don't do anything.  In the next scenario, that you guys start to bother the mother and they are — they don't do anything.  They're held back from doing something. 

In the last scenario, they start messing with the mother, and the guy goes nuts and beats the hell out of them.  That's the unrestrained aggression part.  And what they found was, when they looked at the unrestrained aggression part versus the neutral condition, there was — there's a very large deactivation in this part of the brain, and also the anterior cingulate, in the front part of the brain, sort of decreasing inhibition, and, therefore, allowing the subcortical structures, which are the drive mechanisms perhaps, to come to the fore.

There's also activation, however, in the cingulate, which is sort of this decisionmaker of what they're going to do.  So there certainly is some — you know, some imaging data that sort of suggests that something is going on there.  But we are really in the very early stages of this kind of thing.

I think what's also important is since we've identified impulsive aggression as a problem, we've identified certain biological substrates.  How do we treat it?  There are a variety of agents that can have some effect on impulsive aggressive individuals.  Lithium was the first drug that was shown to be — to do this.  Other drugs include SSRIs and anti-convulsants and some other agents.  I'm not going to be, you know, comprehensive here.

This is the first study done looking at lithium on aggression in prison inmates, and what — this was done a very long time ago — 1976.  You can't do these studies anymore.  And they took these prison inmates and they put them on placebo for a while, then they put them on randomized lithium or placebo. 

The lithium folks' aggressive acts, not the tendency to be aggressive, the actual aggressive acts dropped to zero after three months of lithium, compared to the placebo where it didn't do much of anything.  But, importantly, when they put back on placebo, went back up to where they were. 

So there's two important findings there.  One is that lithium did something to impulsive aggressive behavior.  Two, it was impulsive aggressive behavior and impulsive behavior that responded to the drug.  And, three, all you're doing is suppressing the tendency to behave a certain way.  None of the drugs are going to cure this.  There are some neurobiological abnormalities that can be potentially treated, maybe not in everybody, but in some folks.

And another important finding was that some people liked being on lithium, some people didn't like being on lithium.  The folks that like being on lithium were the ones who felt that the aggressive behavior was not a desired trait, that it was ego dystonic for them.  And they like lithium, they like being treated.

Other people who had incorporated aggressive behavior as part of who they were hated lithium, which means it would be very difficult for them to be treated, because they wouldn't stay on the drug.

Well, the work that I did really pointed to looking at the serotonin system, and so we did studies using fluoxetine, which is a serotonin uptake inhibitor.  We looked at impulsive aggressive folks, mostly personality disordered individuals with this impulsive aggressive IED situation, and looked to see if increasing serotonin in an experimental fashion would make people less aggressive, and it did.  It didn't make everybody less aggressive.  It made a lot of people less aggressive.

But not everybody was responsive.  And if you look at this at endpoint, there's still some aggressiveness going on in some of those folks.

What's important is in these kinds of studies we also looked at the pretreatment biological status, and we had some data to look at — pretreatment serotonin system function, how did they respond to fluoxetine.  And we found, much to our surprise, a positive relationship.

So folks who had really bad serotonin function just did not respond to the fluoxetine, and that actually makes sense, because if their serotonin system substrate is not intact the drug can't really do its thing.  What that also suggests is that the more aggressive somebody is the less likely they are to respond to an SSRI, and that gets us into differential psychopharmacology, which is very important.

We went back and looked at this, and we divided our IEDs into people who have — were highly aggressive lifetime and moderately aggressive lifetime.  And the drug effect was only in these moderately aggressive folks — people who were slamming doors, screaming, shouting, and that sort of thing, maybe occasionally hitting people.

People who are very aggressive — and I don't mean necessarily criminally aggressive — have no effect.  It just doesn't do anything.  The placebo does just as much good as the drug does.  What do you do for these folks? 

Well, Rich Kavoussi, who was a partner at the time, took not these specific folks, but people like them who did not respond to these SSRIs, gave them a totally different drug — Divalproex, a mood stabilizer, and found that it did work.  It made them less aggressive, suggesting that there may be a way to sort of subdivide these folks pharmacologically, not simply on the response to the drug but on the state of their biological system.

And, in fact, a study published last year that I was involved in — this was a study funded by Abbott, who makes depakote, found that if you looked at the cluster B, being the impulsive aggressive personality disorder folks with IED, they, in fact, did respond to Divalproex, compared to placebo.  And these are folks that actually were more aggressive than other sorts of folks.

Now, do these mood stabilizers or anti-convulsants work through something going on in terms of epilepsy?  Probably not.  There's a study from Reeves that came out last year showing that it didn't matter if the EEG was normal or abnormal.  The anti-aggressive response to these anti-convulsant mood stabilizers is really pretty much the same. 

So the method of action is unclear, but probably not by treating some irritable focus in the brain. 

Now, not to leave out psychological intervention, because in point of fact psychological intervention probably ought to be the first thing that you do — there are many types of this — but it's often referred to as anger management.  The best is a system of treatment called cognitive relaxation, coping training — coping skills training, or CRCST.  Mike McCloskey in my group is taking the lead on this and now doing studies in IED.  And, in fact, this works.

We compared wait-list individuals in groups, and you see nice, big effects of CRCST and decreasing aggressive behavior in these IEDs.  What's really happening in CRCST is you are first teaching them to relax and identify when they start to get angry, so they can sort of de-escalate.  And you're teaching them about cognitive distortions, have to do the hostile attributional bias.

Well, maybe this person in the karate match wasn't trying to hurt you or make you look bad.  Maybe they were just trying to win the fight.  That's not so bad.  You're trying to win the fight.  Or maybe it was an accident.  If you give people options of how other people are thinking, it diffuses it.  And then, also you have coping skills.  How are they going to cope with the anger that they have, so they don't reach the point where they act?

And so, in conclusion, I think what some of this work shows is that impulsive aggression, while it is a dimension, you can look at it as a categorical expression.  And IED would be the way to do that.  IED is far more prevalent than anybody ever thought.  The DSM thinks it's extremely rare.  It's not rare — four percent lifetime, one to two percent at any moment in time.

It runs in families, has a substantial genetic component.  There are neurochemical correlates, there are neuroscience correlates, and it does respond to treatment.  Not everybody responds to treatment, not everybody responds the way we'd like to do or as quickly as we'd like to, but they can respond.  My interest in neuroscience is understanding the behavior, not simply from a mechanistic standpoint of biology, but the interaction between biology and environment and genetics, and really look at the whole picture.

Sort of like — actually, what's exciting for me to be at this meeting is to be opposite Dr. McHugh, who was thinking this way back, what, 30, 40 years ago?  Your whole foundation is based on this whole concept of the whole person and biology and temperament and behavior interacting.

Thank you.

CHAIRMAN KASS: Thank you very much.

Could we have lights and the machine off?

Before people get started with their own questions, could I see if I can get from you something that might look like a kind of conceptual model of what we are talking about with this particular disorder?  You talk about general — some kind of general problem likely, say, in the serotonergic system, and also certain suggestions that there might be difficulties in the circuits in particular anatomical regions.

Could you sort of translate, I guess into relatively layman's language, what does this mean in terms of your sort of understanding?  I mean, is this a problem of lack of inhibition?  Is this a problem of hyperactivity of a certain kind of impulse?  Can you put together some kind of a model that would put together these interesting but at least to me still somewhat bewildering findings into a kind of theory of what's going on?  Or are we too early for that?

DR. COCCARO:  Oh, no, no, we're not too early for that.  When we started out, we really had just the serotonin hypothesis.  And I even knew back then that couldn't be all of it, because you really have response — you have a stimulus response kind of thing.

What you really have is predispositional issues.  So people with impulsive aggressive problems are predisposed to act aggressively in a certain way, and they can be predisposed:  a) by genetic factors which come in the genes, they can be predisposed in addition by environmental factors, which could be prenatal, perinatal, postnatal, as well as other kinds of environmental insults that can happen.

So that sort of sets the stage.  What's going on in the brain is a balancing act.  So if your serotonin is low, that neurotransmitter which tends to mediate behavioral inhibition in many systems will be — won't function as well.  So that tends to disinhibit.  But there are other systems that can act in — either in response to that or can be primary.

So you can have, you know, decreased inhibition and increased activation or any combination of those.  And it's really a balancing act.  So there's really this threshold at which anyone here is going to get angry and be aggressive.  For many of us here, that threshold is very high, extremely high.

But if you have the right — the wrong genetics, the wrong environmental insults or influences impacting upon neurotransmitters, that threshold will drop.  So that's the first thing.

So people walk into a situation, as young people or adults, with a predisposition with a threshold.  And then, depending on what's going on at that moment, whether they go over that threshold depends on what's happening. 

So, for example, if somebody has a low.ish threshold and then just finished being on call and is sleep deprived, and they've had lots of coffee, their basal arousal is going to be up here, their threshold is here.  It's not going to take a whole lot for them to reach that threshold and explode.

But they still don't have to explode unless something is stimulating them to respond.  And then that gets into the social/emotional information processing idea.  So they're in a social interaction, because these kinds of things happen in a social interaction. 

So they're in an interaction with somebody, and something happens to them and they have to make a decision about what's going on.  Did that person try to hurt them?  Is that a threat or a frustration?  And how they respond to that, then, further puts them towards, are they going to, you know, reach over that threshold and be aggressive or not?

So it's a complex model.  It's not a simple linear model.  And it's a probabilistic model.  You can't predict — I mean, I can predict if somebody is, you know, given the rest of their lives going to be pretty aggressive or not.  But I cannot predict if, you know, in five hours they're going to do something.  I could tell you, okay, somebody has got low serotonin, they've got high norepinephrine, these sorts of these — they've got bad genes, that if somebody challenges them in a bar, what's the probability they're going to hurt them?  Pretty high.

But they could have an incident where they go a bar, somebody challenges them, and they don't do it.  It's not determined by that.  Everything is probabilistic, and that's how I feel about these sort of things. 

What we're really trying to do is, I think as clinical scientists, is understand what those probabilities are, understand what those mechanisms are, so we can come up with strategies to intervene, to make them — if giving SSRIs is one of them, then we want to do that.  If giving them psychotherapy, cognitive behavior work is part of that, we want to do that.

Is that clear enough?  I mean —

CHAIRMAN KASS: Yes.  Thank you very much.

The floor is open to questions.   Mary Ann, then Carson.  Since the questions left over from last time I think were perhaps directed to Professor Morse, what I thought we would do is we'd have the questions on this presentation, and then at a certain point try to integrate the two presentations and see if we can get the general comments at that point, if that's okay.

PROF. GLENDON:  Some of us work in environments where it's almost taboo to consider that there might be biological differences between men and women.  So one can't help — it's true, it's —

(Laughter.)

DR. COCCARO:  That there is or there isn't?

(Laughter.)

PROF. GLENDON:  So I can't help that this is going to be probably a question which has a very simple and obvious answer, but I can't help being struck by the fact that the studies seem to be confined to male subjects where impulsive aggression is concerned.  And as I read your paper, I was wondering, I mean, you did list testosterone as a factor. 

But I was wondering — that can't be the whole story, right?  There are familial situations where boys and girls grow up in violent households, but you don't have the same incidents of impulsive aggressive behavior.  I wonder if the genetic patterns — probably you haven't studied this, but I'd just be interested to hear you talk about why — how you see the differences between men and women here.

DR. COCCARO:  Well, it's very interesting.  I mean, certainly women can be aggressive.  And, in fact, they are often as aggressive as men.  They're just less effective in being aggressive there.  They're not quite as strong, and so they don't — they don't often hurt the other person as much.

Women are aggressive, and I can tell you that in some of the studies that have been done the findings are in the men and they're not in the women.  But the biology between men and women is probably going to turn out to be that the biological relations we see in men more often than maybe not are also true for women.  So this isn't just in women.

In fact, the studies that I did — the study I showed you, the fenfluramine challenge, was in men, that as in New York.  When I went to Philadelphia and was working there for 10 years, we also did women.  And we see the findings with some kinds of aggression with women, so suicidal behavior, for example, in women does go along with low serotonin function, but not — and some kinds of aggression seems to go with it.  It's not as clean a story in the females than in the males, but it's definitely there.

In the treatment study that I told you about with fluoxetine, they were men and women, and there was no difference in the response between men and women in treating aggression.  And the difference between aggression in men and women is actually not that big, you know, so there is certainly room to explore gender differences.  And, in fact, I was one of the first people to suggest that we need to do that.

CHAIRMAN KASS: Ben Carson and then Jim and Bill.

DR. CARSON:  That was certainly very fascinating, as I was looking at the PET scans that you were displayed.  We certainly use those a lot for our seizure surgery in looking at the metabolic changes.  But I was curious as to whether in fact you see in the anterior cingulate and the rest of the limbic system actual changes when you have a subject on the table who is calm and then becomes angry?  Are you able to actually pick up a change?

DR. COCCARO:  Well, actually, I don't do that kind of work just yet.  We're starting to do fMRI work, but our studies are probably not going to be anger induction in the lab.  But I suspect that we'll — that you can see, you know, some of those changes.  They are functional changes.  I'm not sure there are going to be physical changes. 

There might be some issues where maybe it will make it a little bit smaller or bigger, and that kind of thing.  But these things are going to be matters of degree, and really it's a function that's probably the most important.

CHAIRMAN KASS: Jim?

PROF. WILSON:  Thank you very much.  It was quite informative.  I've read some of your literature.  You know vastly more than I, but what I have read suggests that your presentation is correct.  The task of social science is to explain behavior.  The task of neuroscience and medicine generally is not only to explain, but ideally to help it. 

The task of judges and juries, however, is not to explain or usually even to help but to judge.  Is there anything you've learned from this form of behavior analysis that you think belongs in the courtroom?

DR. COCCARO:  I think perhaps only in the penalty phase.  I don't think any of this work really can, you know, free someone of the responsibility of their behavior.  So I feel very strongly that if you're going to do anything with this work, it really ought to be in the penalty phase, not necessarily they're going to get less of a penalty, but perhaps they get treated, or perhaps instead of getting the death penalty they get life and get treated, or something along those lines.  That's how I feel about it.

PROF. WILSON:  Thank you.

CHAIRMAN KASS: Diana, follow up on this?

DR. SCHAUB:  Yes.  What about the disease jurisprudence?  Do you see it playing a role there?  I mean, you said that you would prefer that these interventions be voluntary.  But could you imagine situations in which there would be involuntary interventions?  What would be necessary to justify an involuntary intervention?

DR. COCCARO:  Well, you know, I'm going to agree with Dr. Morse.  That's not a decision for a scientist, to be frank with you.  But that's something for society at large to determine.  I think it goes to behavior.  How often is somebody doing something, presumably that will correlate with things in the brain.  But we're not really there yet.  I would prefer that we talk about voluntary treatment rather than involuntary treatment.

DR. SCHAUB:  But you also mentioned that you know something about the lithium haters.

DR. COCCARO:  I'm sorry?

DR. SCHAUB:  You mentioned that you know something about the lithium haters, people who value their aggressiveness.

DR. COCCARO:  Yes.  Well, I mean, I think it's — I think it's — this may skirt the issue, but I think it's up to the legal system to make the decision about whether or not they should be forced to take lithium or not.  I mean, I think perhaps they should.  It's going to depend on a case-by-case basis.  I'm not prepared, as a scientist, to endorse that point of view at this moment.

CHAIRMAN KASS: Bill Hurlbut, then Paul and Rebecca.

DR. HURLBUT:  I'll wait until he goes.

CHAIRMAN KASS: Okay.  Paul, and then Rebecca.

DR. McHUGH:  Yes, I enjoyed that presentation very much.  And you are following, in my opinion, the most likely and fruitful design of describing things in terms that ultimately can be translated into brain functions and understood in brain — both in the sense of brain structure and function, but also in the brain's responsiveness to learning.

But I had just a couple of questions.  As I've been following your work and have been fascinated by it, this is an opportunity for me to ask some questions that might be useful to the other members of the group. 

The first thing I just want to understand is you described this categorically in DSM-IV terms, but do you mean it categorically, or do you mean that this is an extreme of a dimension that we might understand and ultimately see that by focusing on this group out at one dimension see something that is otherwise a bell-shaped curve in the population.

The second thing, given that kind of thinking about this matter, one of the striking features about your talk is that you haven't used the ordinary personality or temperament terms to describe some of these features.  You talk about this as being cluster-B, but are the features, particularly the ones that might be related to women and to other people, related more specifically toward dimensions such as the combination of extroversion and neuroticism?

And if that's the case, are these more likely — these patients responding to the serotonin to be the ones that are more extroverted and neurotic versus the ones that don't, turn out to be more either not — don't have such high neuroticisms and even more extroversion problems.

And, finally, you say nothing about the learning process.  Are you thinking of this learning from — in the developmental process out of conditioned learning or out of more social learning of an (Albert) Bandura type or things of that sort that are playing a role in developing and shaping the brain in this process?

DR. COCCARO:  Okay.  The first thing is that I am more of a dimensionalist.  And what we're doing with IED is really focusing in for maybe, to some degree, convenient biomedical terms, looking at the extreme dimension.

The curve is actually a J-shaped curve, depending on the thing you're looking at, because most people aren't that aggressive and then you get these extremes out there.

The second thing has to do with extroversion, the classic personality dimensions.  And, I mean, I've looked at these, and they don't correlate with serotonin measures the way — at least in my studies, the way one would expect.  So it does seem to be more of an aggressive impulsive kind of thing.

As far as the learning issue, I must confess that I'm starting to get into this myself more these days.  And so I haven't really explored scientifically or empirically what kind of social learning we're talking about.  I'm still looking at — I'm still sort of dissecting things out as I go along.  But certainly the learning process is in there. 

I mean, as people grow up, they — you know, if kids — if you have a parent who is aggressive, it sets up a whole bunch of problems, because that person probably has genes that predispose them to being aggressive.  So they're going to pass those genes along. 

Then, they're aggressive to the kids, so the kid gets aggressed upon.  And then the trauma itself is going to have profound changes perhaps in brain structure and function.  And then, at the same time, they learn that this may be one way — and it may be an appropriate way — that one should respond to frustration. 

The parent is angry at the kid because they're frustrated at work or something at home, so they beat the kid up.  So they're sort of learning in that sense.  But I'm still learning about learning processes myself.

CHAIRMAN KASS: Rebecca Dresser?

PROF. DRESSER:  I had some questions about potential justification for treatment or some sort of mandatory use of this — of treatment.  To what extent does this behavior have good effects?  Whether it's something related to the neurotransmitters or this impulsive aggressive behavior could be useful.

I once worked with a person like this who used it quite successfully to intimidate people.  Now it probably wasn't a super extreme case, but I could see that it would have personal rewards.  So to what extent would someone who is considering a treatment be interested in it?  What would that person be giving up? 

And also, are there possibly socially valued behaviors associated with this?  Something — I don't know — creativity or problem-solving ability.  Something that could be useful in a social way that might be involved with this same event going on in the brain that might be lost if we were to try to treat this with a drug.

CHAIRMAN KASS: Like intolerance of injustice.

PROF. DRESSER:  Excuse me?

CHAIRMAN KASS: Intolerance of acts of injustice.

PROF. DRESSER:  Yes, right.  Right.  Intervening to assist.  And to what — I mean, what percentage of people are interested in seeking help?  And what percentage find this a useful way of going about in the world?  And I think we probably would have to confront this issue of when should it be imposed.

DR. COCCARO:  Very good questions.  Maybe I'm not imaginative enough, but I can't see a socially justifiable reason to be impulsively aggressive.  I just can't see it.  I mean, if a person you're talking about knows they have — the question for me about that person you're talking about, do they know they have an impulsive aggressive temperament, and just let it run free reign because it gets them something?  That becomes kind of premeditated in the way Dr. Morse was talking this morning.

So, you know, and that's not appropriate anyway.  I mean, you shouldn't be using, you know, this kind of behavior to intimidate people.  As far as treatment seeking, part of the problem with aggression has been that it's seen as bad behavior.  And it's just bad behavior, and there's no biology to it, there's no science to it, nothing.  It's just bad behavior; we have to punish it.

And because of that, everybody feels — most people in the community feel it's just — oh, you need an attitude adjustment.  So nobody knows about the possibility — the general community doesn't know from — this could be a disorder that has biological, you know, roots that can be treated in a biomedical context.  Therefore, nobody seeks — people don't really seek treatment until either their — their whole lives are falling apart or they're forced to seek treatment.

In a study that I've written up — it isn't published yet — we looked at people in a general psychiatric clinic who had this problem.  About six percent of this population actually had it. And I don't remember the number precisely, but most of the people who had the diagnosis actually wanted to be treated for it, although nobody approached them to be treated for it, because the caregivers — I mean, their treating physicians — didn't see it as something that you treat.

It's just bad behavior.  It's part and parcel of something else that goes on.   So I think that's part of the problem.  And I think one of the reasons that I wanted to develop IED in a better fashion was to do the typical things that people have done for their disorders. 

If you don't — you know, sometimes you want to label things.  But if you don't label things, you can't get a sense of how much is out there.  And if you can't get a sense of how much is out there, you'll never convince anybody that it's a problem worth studying or treating. 

The antithesis of aggression might be social — generalized social phobia.  People are extraordinarily shy.  I can tell you that the drug companies have gone nuts with social phobia.  I mean, they have gotten indications to treat — everybody is treating.  There's nothing wrong with social phobia.  It's a very prevalent condition.  It's bad to have it.

But gee, is it any less worse to be impulsively aggressive and get into trouble?  No.  But are the drug companies going after the development of agents to treat it?  No.  Partly because — I don't think it's a real problem partly because of the lawyers, you know, liability issues and those sorts of things.

So part of the reason of, you know, trying to develop IED as a — and it is in the DSM, but we have just been fixing the criteria, is to raise awareness of the fact that there's really a scientific body of knowledge behind this.  And so that ultimately people would realize, gee, you know, this is a problem just like depression, just like panic disorder, and it can be treated.  It doesn't get you out of anything.  It's just something that, you know, needs to be treated, and I think that's where I'd like to ultimately go with this.

I've actually gotten a little sidetracked with the IED story from the neuroscience that I've done.  But I feel it's important to sort of develop the criteria better and develop the empirical database behind, you know, looking at and studying these individuals.

Have I answered your questions?  I wasn't sure.  There was one I was missing.

CHAIRMAN KASS: Before we open it up to more general things, I have a comment and Jim has another.  Are there other people for that queue?

And this might also in a way echo the kind of question I put to Professor Morse earlier.  I know that you don't see this as altering the way we ought to think about moral responsibility.  Yet as I listen to you, I can't help but think that it might. 

You begin with — you present us Phineas Gage, and the changes that happened to him he's not responsible for.  And you present us porphyria and various other kinds of clear diseases.  We were talking at the break about known temporal lobe seizures, and it's not clear to me, once you develop some kind of a syndrome here, admittedly it's got environmental components and genetic components — and I like very much the rich way in which you lay this out. 

But to the extent to which you see this as an opportunity for prediction, interventive prevention, and therapy, you are in a way beginning to assimilate this kind of conduct to a disease, to assimilate it to the way in which we think about disease.  And maybe it won't affect the judgment of guilt or innocent in any particular case, because you don't, as you say, have predictive power in any particular instance.

But it would surely, I think, play a role in mitigation when people pronounce sentencing.  It would play a role in questions about whether you would recommend, encourage, exhort to, and even compel certain kind of medical interventions down the road.  So that — I mean, I think there's a kind of perfectly understandable and cheerful sense that the understanding of behavior, at least as the law is concerned, is sort of impervious to what science is going to provide here.  But I don't see it.

I mean, it seems to me that there is — and I'm not complaining about this.  I mean, I'm not complaining about this at all.  It seems to me that, to the extent to which we understand some of these people as being analogous to the cases of temporal lobe seizures, it's going to be hard I think to simply say — to remind yourself that, well, if the policeman were standing there, they might not have done it.  That might not be sufficient for the way in which we've come to think about it.

So am I off base with this?

DR. COCCARO:  No, I don't think so.  I mean, my point of view is that we can't use this information.  The only kind of people that I study, because they don't have temporal lobe epilepsy and these other kinds of things —

CHAIRMAN KASS: Right.

DR. COCCARO:  — as explaining away what they did and their responsibility.  And as I was saying to Dr. Morse at the break, I was involved in a case where somebody had clearcut serotonin abnormalities, and he killed his wife, and it was in an act of range.  But it was absolutely clear behaviorally that he knew what he was doing.  You know, he just gave in to his frustration, and he did it.

And the lawyers in the case wanted to make a new law — a serotonin defense.  And I told them, "That's not going to work."  I mean, you should use this in the penalty phase.  This is something that we should be using so that he doesn't get the death penalty.  You know, that there were mitigating circumstances, and that maybe he should be treated.

So my feeling about this really goes not to explaining away responsibility.  In most cases, I think if you — I think you could theoretically come up with a case where, yes, the person really couldn't do it, but even there it's hard, because people don't act aggressively all the time.  Right?  But they act aggressively often enough, and, yes, you're right.

As Dr. Morse said this morning, you know, they know they're going to do it in certain circumstances, and they need to do whatever possible — society needs to do whatever possible to prevent them from getting in those situations.

I think my emphasis is really on strategies for intervention and treatment.  And whether we compel it or not I think is up to society.  You could have a situation where you go, "Well, I'll let you go if you take these medications, and you can prove to us that you're taking these medications.  But if you refuse to do it, we're going to put you back in jail, because we can't trust you out there."

But we're not there yet with the therapeutics anyway.  And predicting — we're not there with predicting.  I'm not sure we'll ever be there with predicting, because all you need is one bad event.  That's it.  Well, he was good 99.999 percent of the time.  Yes, but one time he killed somebody.  I mean, it's not acceptable — I hope — that we send people out who have killed people to do it again.

CHAIRMAN KASS: Thank you.

Jim Wilson, and then we'll open it.  On this, or in the queue?  On this point?  Oh, in the queue.  Jim and then Dan.

PROF. WILSON:  Now I want to make two rather than one point.   In response to Leon's question, I think it's important to realize that in the penalty phase of a criminal trial everything is taken into account — the probation report, the testimony of friends, increasingly of late the testimony of victims, whether the person had had jobs, whether the person was subject to abuse, whether the person had a prior record, the nature of the prior record, the possibility that some of the things that a neuroscientist might add to this is real, but it doesn't alter the situation.

The penalties are determined by judges after a presentence report, unless the case is so cut and dried, or unless the jury is required by law to make the decision on the penalty issue, as they are with respect to the death penalty.  So that the existence of neuroscience does not change the logic of the criminal justice system.  They will take into account all causes of behavior in assessing a penalty, within ranges set down by the law.

With respect to Rebecca's question about does IED or impulsive aggressiveness ever have any value, let me report a piece of research that was done a few years ago, hence may be out of date, though I doubt it.  This was a careful study done of a randomly selected group of people who had — some of whom had gone to the aid of a person in distress.

A woman was being abused, a child was being beaten up, somebody was harassing other persons, and they were studied.  And the one thing that becomes absolutely clear is they were not motivated by concerns for justice or fairness or the rule of law.  They were mad.  They were mad at the offender.

They often got mad, and here the madness was useful.  Now, it would be nice to design a world in which their madness was only reserved for dealing with people who were being threatened.   Happily, we can't control human behavior, but there are positive signs of impulsive aggressiveness.

CHAIRMAN KASS: They didn't jump in to beat the victim?

PROF. GLENDON:  Jim, my recollection of that study is that it also suggested that these Good Samaritans were actually people with a history of rather antisocial behavior.  Is that right?

PROF. WILSON:  That's quite right.

CHAIRMAN KASS: Dan Foster?

DR. FOSTER:  I just want to make a simple statement that's probably obvious to everyone.  But there seems to be a tendency sometimes, like this morning, to jump way ahead of the implications of the science that's involved in the neuroscience and make assumptions that the answers are there. 

We always start — and Dr. Coccaro was very cautious about — here with correlations, so there are correlations between the serotonin system and some behavior.  And he's very cautious to say, you know, that that's not the whole answer.  You have to way beyond correlations.  You start with them.  You've got to go way beyond that, and the same thing for the imaging.

For example, the PET scans are all — almost all just an uptake of glucose into an area where you can look at it.  Nobody has even begun to look at the role of other nutritional factors about glucose uptake — for example, fatty acids and other things that may alter — that are changing throughout the day when we eat, and so forth, that may alter PET scans and their relation to things.

I just — all I want to say is that we need to be very careful to not put too much emphasis on where we stand now and its subsequent social or other behaviors.  We have to start.  You know, it would be — it would sort of be like looking at genes before we knew the genetic code. 

You know, in other words, the things that we're looking at are very — one would have to say very primitive, and I think we just need to be cautious about trying, therefore, to put a structure for the courts, and so forth, based on this until we know more about what's going on.

It is — I think Mike would be better to say than I, but, I mean, it is a very early time here, and we need to be cautious about the implications of these things.  That's all.

CHAIRMAN KASS: Thank you.

I think we should turn to the general comments, if we could.

DR. McHUGH:  Can I just say one more thing, just to draw out the answer to your question about this being a dimensional matter?  It is a dimensional matter that's being studied primarily amongst people who are complaining about this.  You're not going out and studying the population in the world.

If this is a dimensional feature, then we presume that there are people with this dimension, lesser or not so severe, that don't come to doctors' attention, and those people might be very well — doing very good work out there, and this dimension may be serving great purposes for them in some other way.  Is that not possible?  I mean, we are looking at this from a clinical — in a clinical population, and if it's a dimension, a human dimension, then we're getting a skewed view of the population and of this dimension.

DR. COCCARO:  Well, yes, to some degree that's true.  I can say that we don't have an anger clinic.  I mean, people come in because we put out public announcements saying that we're studying this kind of thing, and they come in to see about that.  So they are sort of clinical, but they're not pure clinical in the sense that they're coming in and —

DR. McHUGH:  But it's not a population survey.

DR. COCCARO:  No, that's not a population survey.   The twin studies we do are population-based.

DR. McHUGH:  I see.

DR. COCCARO:  Yes.

DR. McHUGH:  But then, to the answer to the question, would these perhaps be helpful, we might look at people who are also asked to be aggressive and see how many of them, in fact, fall into these kinds of brain scan and biological manifestations.

By the way, just to back up what both Jim and Mary Ann were saying, even before we were doing brain scans and biological explanations — again, psychologists like Joe Matarazzo and other people of that sort were looking at criminal behavior in policemen. 

And with dimensional features, they found they were remarkably similar in their — in these temperamental characteristics, although they were very different in their social understandings, and the understandings of what they had ultimately learned over time worked for them and worked for all of us.  Thank goodness we have them, and they are ready to go out and do good work.

Do you plan to — again, to continue your themes of this dimension and answer Rebecca's question in this theme, to start looking at people of that sort who aren't coming to you complaining of their anger, but are saying, "Gee, you know, that's what's making me captain or master sergeant or all those wonderful people that we need."

DR. COCCARO:  It would be a very exciting study to do that.  We can probably get at some of that with our twin program, because we have a population base — the twin program from Pennsylvania, we bring them in every week.   And these people are not coming in for treatment for anything, but they've got stuff.  They've got lots of psychopathology.  And as we sort out what they have, we can probably do that.

CHAIRMAN KASS: Bill Hurlbut, and then Diana.

DR. HURLBUT:  This is kind of a subset of Leon's question earlier about culpability, and it goes to the root of the question that Dr. Morse was bringing up implicitly — the notion that eventually you might have some findings from neuroscience that reach the level of foundational revision of our understanding of human nature, and, therefore, altered views of culpability as such.

What I want to ask you about is sort of a general topic.  But when you say that the mind — that the human being is a conscious, relational, intentional being, there's a lot packed into those three words.  And take for example the word "intentional."  Okay.  It's aboutness or relating to something outside yourself, a purposefulness, a whole context actually.  Human intentions are based on a whole large image of the world in which they live.

And in a sense, as each of us develops individually, we undergo a process of personal construction, where we put together a large view of the world based on experience, observational and interactional kind of relational dynamics.  So we eventually become rational in a sense of a resonance along a sort of alignment of the ratios of the way the world is.

And our behaviors, then, are aligned with the realities we see.  We develop images and ideals according to those, and ultimately I suppose it's fair to say that our motivations and, therefore, our actions are deeply rooted in our most foundational aspirations or images of what life actually is.

So, then, for the healthy person at least, one could say that one's construction is inseparably related to one's moral disposition, and goes finally down to the level of what you might call a philosophy or a faith, a kind of deep story about what our existence is.

Now, do you accept all that as a reasonable start?

DR. MORSE:  I accept a lot of it, and enough as a premise that I'm happy to go with you.

DR. HURLBUT:  Okay.  What I really want to ask goes to another question about that.  If one takes that constructed identity, and, therefore, constructed moral mind seriously, then what I really wanted to ask you about is the question of Phineas Gage or, to put it more relevantly, the analogy that we would use with that obvious pathology extended to a much more prevalent pathology of sociopathy, which, according to some people, is as high as 50 percent of people on death row and 20 percent of people in the penitentiaries.  Some people say that's what the incidence of those is.

Okay.  So what I want to ask you is this.  When you use the word "rational," aren't you smuggling in already a huge premise about the way the mind is as though we can stand outside of the world and look at the world the way you've said we couldn't?  Is not the rational mind actually a strangely emotional relational mind?  And what do you make of — well, put it first, isn't the development of childhood moral responsibility what you'd call the infancy excuse or — somewhere that was used in our readings.

What's going on in development of a child?  There is a development of the moral mind, among other things.  And what happens if your capacities for this are diminished.  And here I'm getting at the broader category of sociopathy as focused by studies of Phineas Gage like people done by Hannah Damasio, where she found that if infants had certain lesions, they would never develop moral capacities, whereas if those same lesions took place in late adolescence, they would have at least routine moral alignments.

So what I'm asking is a broad question.  Might all this revise our sense of how the moral mind is developed, such that we start to see that there are some people who are almost what you might call morally color-blind, that it's not just that everybody is rationale but that the rationality of being is actually as strangely — I don't know what a right word would be — but relational, dynamic, that some — that it's not just impulsivity but a fundamental moral incapacity that might be underneath a lot of crime.

And you know what I'm asking here, right?

DR. MORSE:  I do.

DR. HURLBUT:  Okay.

DR. MORSE:  Well, that's a very, very hugely broad and deep question, and there's also a specific question.  The specific answer would I think also allow people to infer the broader answer.  And since it would be immoral to keep people from lunch, let me do the shorter form.

You've asked about sociopathy.  I know I'm dealing with a sophisticated crowd here, but let me just briefly say that there is a difference between the DSM-IV antisocial personality disorder, which is largely behaviorally defined.  You get in trouble with the law, you have problems paying your bills, it's all behavioral.  And then what's known as the classic psychopathy concept defined most well-known by Hervey Cleckley in the Mask of Sanity, which is more a psychological concept having to do with analogy of the short form, failure of guilt, failure of empathy.

And we, in fact, can measure that now very, very well behaviorally with something called the Hare Psychopathy Checklist Revised, which is an enormously powerful and robust measure for picking out these people who seem to lack the moral capacity, and where there is an enormously powerful association between antisocial conduct and high scores on the psychopathy checklist.

All right.  Having said all of that, so now we know people out there who lack these capacities.  Now, think about what it is that allows you, in the face of temptation, not to do things you know you ought not to do.  It's not just there's a policeman at your elbow, so that's, in a sense, an unfair test, and Dr. Kass is right.

It's what you have a capacity to think about in terms of, gee, I'm going to feel guilty.  What would it be like to be a victim of that myself?  You have empathy.  You have these internal, if you will, checks.  Now suppose you don't have those checks.  It's going to be much more likely that you are going, in effect, to offend.

Okay.  So now comes the question.  We have these people.  They're highly — and they are overrepresented in prison.  And by the way, the overlap between antisocial personality disorder and hare psychopathy is large but not perfect by any means.  And it's assumed that somewhere between 40 to 60 percent of people in prison have antisocial personality disorder.  A somewhat lower number are — suffer from psychopathy as defined by the hare.

Should these people be held morally responsible?  The answer of the law is yes, for precisely the reason Mr. Hurlbut said.  They know what they're doing, they're instrumentally rational.  They're A to B rational.  You know, they have a premise, they can get there from here.  They're not out of touch with reality in any gross way, but they lack this particular capacity.

The philosophers are almost uniform in believing that they ought not to be held responsible, because one of the necessities for moral rationality as it were, was the ability to feel guilt, to have some empathy.  You don't, in other words, have the tools you need to reason well about what you have reasoned to do if you don't have guilt and you don't have empathy.

I'm on the side of the philosophers on this one.  I would say these people are not morally responsible for what they do.  By the same token, I'm then entitled to control them if they are particularly dangerous.  I mean, they are psychopaths who are CEOs of major corporations, and the like, and —

(Laughter.)

— perhaps we don't need to control them.  People who are, let's say, murderers, rapists, and the like, maybe we do.  But it's — again, having the science of this does not answer the question of what we ought to do with these people, either morally or practically.

As far as your deeper question, I have one sentence on that.  Yes, our identities are socially constructed.  Yes, the concepts of rationality and intentionality are normative.  There is no obvious right answer to what counts.  But I would like to think, since we are at least in some fundamental ways all the same, wherever and whenever we have been born, wherever and whenever we've been born, that there are certain human capacities that we do have in common that have sort of a fundamental base, or what I mean common sensically by rationality and intentionality.

CHAIRMAN KASS: Diana, and then with one last intervention we'll break.

DR. SCHAUB:  I just want to ask you for a prediction.  I mean, you sketched out that we have dessert jurisprudence, and we have disease jurisprudence.  Presumably, in the past, the disease jurisprudence was a very small slice of that.

Even without some kind of foundational discoveries or hard science to support it, do you think we will increasingly move towards the disease jurisprudence?  I mean, the scientists might be telling us to be cautious, but will citizens be cautious?  And that this shift towards disease jurisprudence might not be out of softheartedness at all, but out of a desire for more social control.

You've already said that we see this in the case of sexual predators.  We're very frightened of sexual predators.  Maybe we're not as frightened of, you know, impulsive aggressive people.  But do you think we will see a shift in that direction?

DR. MORSE:  I hesitate to make a prediction, so all I can do is sort of talk about what will be the forces at work.  The reason these mentally abnormal, sexually violent predator commitments were instituted, we used to have them back in the middle of the 20th century.  They were — they fell into destitute or were abolished.  Then we had them again starting in 1990.

It was the fear that we can't keep people in prison long enough sometimes, and we've got to control them when they've very dangerous.  The way you do that is you "medicalize" the problem.  You convert to the disease jurisprudence.  You then claim these people are non-responsible, and then you have warrant in our system for holding them involuntarily because they're not responsible.

If you look at the criteria in these mentally abnormal, sexually violent, predator commitment cases that the Supreme Court has approved, all you have to do is take out the word "sexual" in these criteria and just leave in the word "dangerousness," and they would be precisely the same.

And in terms of the definition of who qualifies as abnormal, they would be precisely the same.  There is no doubt in mind whatsoever the Supreme Court would approve such broadened form of disease jurisprudence if legislatures wanted to do at.  At least the present Supreme Court.

And by the way, in approving the criterial language for these, it was nine to nothing in the Supreme Court of the United States.  Everyone agreed. Gee, these people — you know, the legislature says they can't control themselves, they can't control themselves.  This is okay.

If people began to fear the IED folks that Dr. Coccaro has so well described to us, could we have expanded disease jurisprudence?  Absolutely.  I see no block to doing it constitutionally if legislatures wanted to do it.

We are particularly afraid of sexual folks — sexual predators in our society.  If we got particularly afraid of IED folks or anybody else, it is I think, if you will, legally doable. 

CHAIRMAN KASS: Thank you.

Before breaking, Mike Gazzaniga, if I might ask, is there something you want to comment on as the Council's resident guru on neuroscience and —

DR. GAZZANIGA:  Well, both speakers took my position, so —

(Laughter.)

— they said it better than I could.  So I think neuroscience has very limited, if any, role in the courtroom.  And I think the neuroscience that is done is — does relate, is probabilistic and correlative and not at all — do we understand it enough to have it playing — or being used in a causal role?  So my view was represented well this morning.

CHAIRMAN KASS: Very last question to you and the two speakers.  Does that mean if — if the NIH were to set about a major study on the neuroscience of criminal behavior, that we should be for it or against it?

DR. GAZZANIGA:  It depends who gets the grant.

(Laughter.)

DR. MORSE:  For me, it would depend entirely on the design of the study and the purpose of the study.  I can certainly imagine studies that would be useful, and I can imagine studies that would be a waste of the taxpayers' money.

CHAIRMAN KASS: Since you do some of this research —

DR. COCCARO:  Yes, I do it, and I'm funded to do it.  Although I don't really study criminals.  I would be in favor of it, but, yes, I mean, we have a peer review system that keeps that in check, so that, you know, the study design is very, very good, and that we're not wasting taxpayers' money.

But I'm all for, you know, studying more and more about this, so we can come up with targets for intervention.

CHAIRMAN KASS: Thanks to both of you for very clear presentations and great generosity and forthcomingness in the exchange.  Please join members of the Council for lunch, if you can.

(Applause.)

And, Council members, we reconvene at 2:00.  You have an hour and 20 minutes for lunch.  That should be enough.

(Whereupon, at 12:36 p.m., the proceedings in the foregoing matter recessed for lunch.)                                                             

SESSION 3: AGING AND SOCIETY: A COMING CRISIS IN LONG-TERM CARE?

CHAIRMAN KASS: For the rest of this meeting, we turn from the topic of neuroscience, brain, and behavior, to questions having to do with aging, dementia, caregiving, and society — a series of topics that have a certain internal coherence to them.  I think the coherence — I don't have to lay it out, but I think we will see what it is as we go through it.

I remind you, since there are some people who wonder where the ethical issues are in all of this, that among the first responsibilities of this Council, as enunciated in the Executive Order, is that we should conduct fundamental inquiry into the human and ethical significance of advances in biomedical science and technology.

And while there is no particular technological innovation here whose ethical significance or human significance we are looking at, we are, in a way, looking at the human and ethical significance of the aggregate effects of every successful biomedical science and technology, which, amongst its great blessings, has produced a healthy human population into the '60s and '70s and '80s in an unprecedented way.

But as a possible cost of that success, we have the human significance of a growing population that is increasingly aged, and a population in which, although many people are healthier for a lot longer, most of us have to look forward to a protracted period of decline and debility in need to care. 

And it seems appropriate for this Council to look into this question and to try to lift it up to public view, if it can find the right means of doing so. 

We started two meetings ago very modestly with a little paper by Gil that explored the question of the concept of a demented person, and a discussion led by Rebecca on the limits of advanced directives — very small, modest beginnings. 

The last time we broadened the scope very widely, beginning with two views of the aging society: A social science view with Robert Binstock talking about Social Security, Medicare, and various related matters, and offering, in fact, a couple of challenges for this Council, one of which we will take up tomorrow. 

And Thomas Cole's sort of review of the meaning of aging and old age in modern American society, and raising for us what he takes to be the major cultural question, namely some kind of doubt about what it actually means to be old and especially infirmed in today's world, absent the kind of iconographic — the kind of coherent views of the life cycle to which his iconography pointed us for previous ages.

We had a very fine presentation from Dr. Selkoe on the research in Alzheimer's Disease, and a companion presentation from David Shenk on some of the travails of having and caring for people with Alzheimer's Disease, and then a rather thorough treatment of the dilemmas of the caregivers, familial and institutional, from Geri Hall.

And that's where we were last time, and the question was:  how could we follow up that sort of broad discussion to try to produce certain kinds of greater focus?  In the sessions after this one, we will take up certain particular ethical matters, questions of the ethical attitudes of the old and soon to be old and dependent toward their beloved young descendants, and then the very difficult question about medical intervention in the presence of severe, moderately severe, severe Alzheimer's Disease, triggered by a fine paper by Eric Cohen presented — we'll talk about tomorrow.

And then we will have a public policy session with Robert Burt's presentation in the second session tomorrow.  The first session is, in a way, the broadest and to some extent least concretely focused.  But I think that that's not inappropriate.  After the last meeting, Mary Ann Glendon suggested that one of the things the Council might do would be pick up the suggestions made by Robert Binstock and others at the last meeting that we really are on the threshold of a large crisis in long-term care in this country.

And it would be important for the Council at least to explore the degree to which this is so, and to try to understand both its character, its dimensions, and its underlying causes.  And one could raise this question — if we were to proceed, really, in the spirit of trying to have a general diagnosis of this question, is this mainly demographic?  An economic problem?  Coupled with the failure of medicine to do adequately, to somehow eliminate the need for such care? 

Or is this also a cultural or ethical or spiritual problem as suggested in part by Thomas Cole?  And if it is the latter, to what extent does our tendency to treat it largely as an economic and demographic matter aggravate those aspects of it that might, in fact, be matters of culture?  Are we concerned in the sense of caring for the aged and the dependent? 

Are we interested in just caring for them — that is to say, meeting their needs?  Or do we have a stake in caring about them and caring for them, not simply as needy creatures but as people still connected with us, full members of the community?

We have several papers that are in the briefing book that are intended to trigger this kind of discussion — a discussion of how well do we understand the difficulties that we face in coming to grips with the need to care for those needing our — needing care in the coming Geriatric Society, not just the people with Alzheimer's, but people with other kinds of severe dependencies that make it impossible for them to look after themselves.

Joanne Lynn's paper, not really presented as a long-term care problem, she treats it as end-of-life care.  But because she presents end of life as possibly lasting a very long time, in fact, she has I think successfully smuggled the long-term care issue under the rubric of how you deal with people at the end of life.  And there are several striking things in that paper that I hope you noticed and we can refer to it as we wish.

Mary Ann has written a very short paper, kind of a synoptic view, calling attention to what she thinks is the dimension of this question as well as some of its critical features.  And Peter Lawler has written a kind of cultural commentary, trying to point out as to why, if insofar as we're talking not just about economics and demography, but about the cultural, ethical, and spiritual need to care about and not just for, why we face certain kinds of difficulties in — given our cultural predilections that he outlines there.

That I think is to set the table for a discussion which will go where it will.  I've asked a couple of people if they might be prepared to offer beginning comments, and let me start with Diana Schaub.

DR. SCHAUB:  Leon asked me if I would be willing to start the conversation off this session.  But I confess I don't know what to think after reading the three essays assigned for the session.

Mary Ann Glendon tells us that a caregiving crisis will soon be upon us, a result of living longer, propagating less, and sending women off to work.  She suggests that the Council could do some good, not by dealing in policy prescriptions but simply by sounding the tocsin and sounding it in such a way as to broaden the framework for discussion.

I don't know whether Peter Lawler broadens the discussion, but he certainly deepens it.  We learned that the caregiving crisis is not just a result of demographic shifts, and shortages of women, power, and money.  It's more profoundly a crisis of our culture.  We find ourselves increasingly in need of care, and increasingly unlikely to be cared for. 

This is the predictable — and Peter seems to suggest inevitable — result of our individualism, which devalues care as a fundamentally unproductive activity.  In seeking to live carefree as radically, self-sufficient individuals, we are destined to live without proper care in our ever-lengthening periods of great need. 

The only true solutions that Peter speaks of for those with Alzheimer's — being at home with large families, or attended to by the Sisters of Mercy — are, as he admits, solutions that are evaporating.  His is a grim diagnosis.  If he's right, then our condition is irremediable, inoperable.  We can understand it, but we can't do much about it.  Peter does not suggest that Americans could ever become more welcoming of either giving or receiving care.

Mary Ann spoke of the need to cultivate a certain tragic sensibility.  Peter digs deep into that dark ground. 

The third paper, the white paper from RAND, takes a very different approach.  It has a very American can-do spirit about it.  The authors speak not of a crisis but of a new set of challenges — challenges that lots of folks are already thinking about and addressing through a growing body of research and certain pioneering programs.

The authors deliver the good news.  We can adapt and reform our health care system.  We've done so before.  The hospice movement of the last few decades was a response to an earlier shift in the needs of the sick.  With the prevalence of cancer, a new class of patients emerged — the terminally ill and dying. 

The authors state that what we need now is a new movement to respond to the emergence of yet another class of patients — the declining, the frail, the demented.  This movement would combine curative and palliative aspects in their proper and ever-shifting measure.  Treatment would focus more on the various needs of the patient, less on medical diagnosis.

So the white paper gives a number of concrete suggestions as to how this tailoring of services to needs might be accomplished.  It sketches a cure for the ills of caregiving. 

I just have a couple of questions and a couple of observations.  To the extent that the crisis or challenge is demographic, is it also temporary?  Is it just a matter of seeing the boomers through to a decent exit?  I realize that many of the trends will continue — longer life, fewer children, women working, and perhaps our fundamental orientation towards individualism will continue.

But will those things all be more manageable once the boomers have passed, or not?  This particular generation, of which I am a tail end member, has always caused consternation to society by virtue of its numbers and by virtue of its character.  As it moves through life, it wrenches all thought and energy and resources to its concerns.

So I'm actually not too worried that we will fail to pay attention to the elderly boomers.  They've always been vocal and insistent about their interests.  They've also been inventive.  I suspect that they will change the shape of retirement.  It will be less retiring, but there will still come a time when the young old become the old old.

And I guess at that point I put somewhat more faith in the cash nexus and the laws of supply and demand than Peter does.  When the demand is there, wages will rise, workers will come.  Many of them will probably be immigrants, not fully acculturated to American individualism, and so maybe wiser about the ways of caring.

Caregiving as a calling may be superior to caregiving as a profession.  But that shouldn't prevent us from doing all we can to raise the standing of the profession and to attract into it those with a true calling.

Finally, I want to quarrel just a bit with a point that both Mary Ann and Peter make.  They both refer to our individualism-induced obtuseness or obliviousness.  Mary Ann speaks of how we tend to relegate obvious facts about human dependency to the margins of consciousness.  Peters says that more than ever before we experience ourselves simply as individuals.

And yet, whatever our declared views, we in fact lead care-filled lives.  Our careless language is not reflective of our care-full lives.  And they both — they do acknowledge this.  Mary Ann says it's still a fact that almost all persons spend most of their lives either as dependents or caring for dependents.  And Peter acknowledges that almost everyone today is some mixture of productive individual and loving caregiver. 

The wisdom of women about the sources of human happiness in the ends of life is now accessible to men, just as the productive knowledge of men is now accessible to women.  That doesn't seem to me to be a bad basis for devising public policies that support private life.  It may also be why the coming challenges are not more widely perceived as a crisis.  It's just the way of things.  We know our parents are aging, and we know that we will be there soon also.

Alexis de Tocqueville, an author that I know Peter knows very well, wrote about the detrimental effects of individualism.  But he also wrote of the uniquely American doctrine, which he calls "self-interest rightly understood," that counteracted the worst effects of individualism.  Tocqueville describes how an enlightened self-interest constantly brings Americans to aid each other and disposes them willingly to sacrifice a part of their time and wealth.

We clearly have a long-term interest in long-term care.  As Mary Ann says, if the outlook for dependents is grim, the outlook for everyone is grim.  Reflection on ourselves could spur improved care for others. 

Tocqueville also notes that frequently Americans are better even than their self-regarding doctrine.  They are capable of pure generosity.  On occasion, they care for others, not only because they believe it redounds to their own advantage, but out of the goodness of their hearts. 

So I guess I'm suggesting that we have some resources with which to meet the coming crisis — the much maligned cash nexus, our Tocquevillian self-interest rightly understood, and small but inexpungable reserves of human love and generosity.

CHAIRMAN KASS:  Thank you.

Someone else with — Jim Wilson?

PROF. WILSON:  I would like to expand a bit on what Diana said.  I hadn't been aware of her views, but they correspond very closely with my own.  I think in trying to think about our responsibility to care for older people, we run a risk in this country from drawing our generalizations about this country from what we know of this country in its present state.

I think we would be well advised to look more broadly, and if someone wishes to pursue this issue we ought to look more broadly.  Let me give you one bit of data that illustrates the problem.  The survey is 10 or 15 years old, long before we began to worry earnestly about the retiring baby boomers, but I think it suggests a striking difference.

In the same year, survey analysts asked a representative sample of Swedes and a representative sample of Americans the following question:  who do you think should care for older people?  Two-thirds of Americans said, "Their children."  Eleven percent of Swedes said, "Their children."

Now, I suspect, without drawing too much significance to this study, that we could array the countries of the world along a spectrum from those who make the natural assumption that the children are caregivers to those who make the natural assumption that the bureaucracy or someone else or the government is responsible.

Now, the United States may be moving along this spectrum, but the survey, to the best of my knowledge, has not been repeated.  So I do not know whether we've moved very much.

Let me end as Diane started by speculating on some of the reasons why, just using this survey, Americans are a more caregiving people than our friends in Sweden.  And I suspect our friends in several other European countries.

It's not simply enlightened interest — a self-interest rightly understood.  It's the religious basis of self-interest rightly understood, about which Tocqueville also spoke.  This is the most religious industrialized country in the world, and I think the impact of religion on care is profound, both institutionally, because churches and synagogues get involved in it, and indirectly because churches and synagogues reinforce that belief among their members.

I think the second reason is we have a relatively weak welfare state.  We did not immediately follow Otto von Bismarck's suggestion made to defeat his liberal opponents in Prussia at the time he made it.  We did not follow the British experience.

And most of my colleagues in social science regularly reproach us for not having a bigger and fatter welfare state.  That may be a good or a bad criticism, but one of the consequences of it is is that we rely on each other more, because we are not confident that the welfare state will make a difference.  Indeed, a great majority of young people, when polled, say they do not believe Social Security will be there for them when they retire.  I think they're wrong, though it may be there in somewhat different form.

And the third reason is that this is a country, unlike other countries, of family-oriented immigrants.  Not all immigrants come here with families, and some who come here go back to the country of origin. 

But if you look at the Asians and Latinos who do come here, you discover they come here with a family orientation which produces two happy things for us — a large supply of younger people, some of whom can be hired to do work we do not wish to do for ourselves, but, much more importantly, a belief that family responsibility is critical.

These are thoughts off the top of my head, and each — and perhaps all may be disproved by deeper inquiry.  But my general point is, do not generalize about what the United States is like by making excessive generalizations about our individualism.

CHAIRMAN KASS:  Peter?

DR. LAWLER:  Let me degeneralize a bit.  I wrote the paper to be provocative, but, in general, I agree with Professor Wilson that what makes America different from a raw statistical point of view — and I'm not a statistics guy — it would be evangelicals and immigrants.

For example, I read an article in The Washington Post last week written by some guy from the New American Century, whose name I don't remember right now, and it said something like this.  That if it weren't for people who regularly went to church, our birth rate would be about the same as France.  This is the key variable.  Which would mean that, in fact, my paper is full of exaggerations, and the exaggerations would be along these lines. 

I said Americans experience themselves more as individuals than ever before, and I'm sticking with that.  But I didn't say Americans experience themselves always as individuals, because if that were the case we would be monstrously unhappy all the time.  We're individuals when we pursue happiness, but when we actually are happy we're something else — creatures, family members, friends, citizens, neighbors, whatever.

So there has always been that great American mixture described by Tocqueville that we're individuals part of the week, not individuals the rest of the week, and this is actually a pretty good solution.  But it's a solution that in some ways is intrinsically unstable, although I perfectly agree with Diana that we will never individualize love out of existence or anything like that.

So if what makes America different is we have immigrants who are family-oriented, we also notice that lasts for a generation or two, that birth rates in immigrant groups drop off after they're here for a generation or two.  But in terms of experience ourselves, say, as creatures, America is the land of religious revival.  And so the story of Europe may have been the story of constant religious decline, culminating in some post-religious era. 

That is not at all the story of America, and so in a full, non-generalized account of America right now, we would have to include that fact.  So I'm sticking with the we're more individual than ever before.  I didn't mean to say we were individuals and nothing more.  I just wanted to say that as we become more individualist, caregiving becomes a dilemma for us. 

But I also say in the paper that we're not really individuals all the time, because if we really were to think about this, we would kind of then destroy the non-producing class, and none of us wants to do that.  And so as typically middle class people, we're caught between being individuals and not individuals, and so the average American in a middle class family wants to care for his or her parents.  Who can deny that?

On the other hand, he wants to be productive.  There is a conflict in the life, and it's — the conflict is getting progressively more difficult.  So I didn't mean to be, although I probably was, as doom and gloom as Diana said.  I don't want to be so deep that I'm not optimistic in some respects.

I have some faith in the cash nexus, but not all that much.  I do have, to say it the corny, old-fashioned way, somewhat more faith in the human soul, and not only the American soul finally.

CHAIRMAN KASS:  Dan?

DR. FOSTER:  It may be too early to say this, but — and Leon and I have talked about this before.  My concern about this topic is not that there's a problem.  It's been predicted for a very long time — and there are many people looking at it from the RAND Corporation to anything else.

The question I want to see — I want to be answered about or to have us come to an answer about is rather than just saying, well, we need to talk about the ethics of the aging population, is to ask ourselves, what question are we really asking?  I don't think you can do anything if you don't have a question that is susceptible to discussion and answer, rather than a generalization that almost everybody who works in the world knows about already.

And, I mean, I just don't think it — we're going to be very helpful to say, well, we ought to be kind to our parents, or we ought to do this, that, or the other.  They're either some real questions or they're not, and that's what I've been struggling with. 

When we started out on the stem cell, we had a real question.  Yes or no.  Yes or no.  I can't see what it is that we want to do, and I think we're going to be wasting our time if we just keep hearing reports about how many elderly there are and what their problems are and what dementia does for it, and so forth.

Now, you could be precise.  You could say, well, okay, let's look and see how we might deal with this problem if we were looking at policy or the government.  That would be something that you could look at. 

You talk about the diminishing birthrate in France.  What France does is they now have — you know, everybody can have a — that has a baby can have a good place to get them cared for, so that the mother can still go back to work, and so forth.  There are social solutions to this if you want to pay enough money to do it, and you could say, "Well, we want to do that."

I mean, I think everybody agrees, if you just read the newspapers, that we are not replenishing young people who are workers.  You saw The New York Times about Pittsburgh, how they couldn't replace the mill workers, and so forth and so on, there. 

Well, if you're going to do that, then you have to give the incentives to women in a new age that they can be maternal, and they can go into medicine or science or law or whatever and have their children taken care of well without having to sacrifice their — that would be an approach that you could say would be a specific thing that you could look at.

But what I'm worried about is just muddling around in generalizations that, in the end, that nobody is going to pay any attention to, or is likely not to pay any attention to. 

Now, I know from Leon's letter that I am a very marked minority in terms of this Council.  I mean, he says that there are lots of people who think we ought to do this.  Well, how many times are we going to listen to the fact that — you know, that a caregiver for a person with Alzheimer's Disease, and so forth, is going to sacrifice things?  You can't be productive or whatever.

So I just want to throw it open early on, and almost like this being we were talking at lunch today about, you know, sometimes maybe we needed Executive Sessions to just hammer this through. 

But what I would like to be convinced of is that at the end of this discussion, we do something that everybody believes is meaningful, that's answered — several specific things.  They are very big topics, if you're talking about spending more money, you know, for health care and for long-term care, and so forth.  I mean, it's — maybe we don't have the expertise to do that, but that's what I would like to hear. 

I mean, I don't — I don't want to sound mean or anything, because I've — you know, I mean, I know about taking care of dependents, and so forth.  But I just want to have — I really want to know what is the question we're going to address?  Or questions, if there are more.  And how will we make something worthwhile out of it, which is not only meaningful to us but meaningful elsewhere?

Some of you have read the Nature article that just came out, which I thought was a very — an assessment of our Council.  And one of the criticisms was, which was an unfair criticism because we were called into organization to address specifically the biomedical things and the stem cell things.  That's what we were told.

But we were criticized because we never addressed the big problems of ethics, of bioethics, you know, like health care, and so forth.  I thought that was — was true, but not — it was unfair in the sense that that's not how we were constructed.

But this, to me, is worrisome, because I can't see — and I've tried to think about it a lot since at the last meeting when Leon and I talked about it.  I'm trying to find myself saying, okay, you have a free feel.  Give us a question that you think that would be good for us to address, because I'm not smart enough to come up with a question or questions. 

I'd really like that to be a subject of this general discussion this afternoon.  What is it, specifically and in hard-nosed fashion, that we hope to accomplish and answer?  Mary Ann is already after me, so that's —

PROF. GLENDON:  Do we have to think in terms of a specific question?  This really goes to the nature of what we do here as a Council.  Are we supposed to think in terms of a specific question?  Or is it enough to note that the society is facing a set of challenges that are, in several ways, unprecedented? 

And that if — if they continue to be discussed within the framework that Alan Greenspan, again, warning for the second time this year on the problems of the Social Security system, if they continue to be addressed simply within an economic framework, decisions are going to be made about caregiving, about dependency in our society, that will affect all of us, young and old, without consideration of the non-economic dimensions.

So it seems to me that it's not likely — democracies, as Tocqueville taught us, are not very good at thinking about the long term for a whole lot of reasons.  It seems to me one of the services that a body like ours can perform is to think a little bit about the long term. 

One aspect of this whole problem that makes it unprecedented is something we haven't talked about yet, and that is the elderly are not the only dependents in our society.  There's the problem with who is going to care for the very young.  And one thing that happens, that predictably will happen in an aging society, is there are going to be fewer and fewer children. 

This is not only an economic problem for the labor force; it's a problem for how we think about the very long — out of sight, out of mind.  We are increasingly becoming a very adult-centered society.  Turn on your television.  Look at MTV and you'll see what I mean.  The more we become an aging society, the more we become an adult-centered society, the more we have to worry about children and child-raising families who are now in a minority.

So without framing a precise question, I do think that there are dimensions of this demographic phenomenon that are — the reason we care about them is that they are cultural.  It's not just a demographic problem.  It's not just an economic problem.  The aging of the society is going to affect our culture, what kind of society we become, in ways that are hard to foresee. 

And if we just lurch along and treat it as an economic problem, we may end up in an America that is not the place that all of us hoped and dreamed it would be.  That's a little start.

DR. FOSTER:  Well, let me answer first.  I did try to put an S on the question to questions.  I don't know that there's one thing.  I certainly agree with you in terms of the problem, not just economically, of children.  The estimates are that at the end of this decade 60 percent of children in this country are from one family — you know, one-parent families. 

There are not going to be families available here — even in this very religious country, there are not going to be families to take care of people.  And what that means is that we have to punt the care to somebody who is not family, in my own view.  So I can see no exit from this at all, either in terms of the child care, and so forth, to enhance the birthrate in this country, to the care at the end, because the traditional care, I don't believe, is going to be there.

Let me just give you a little anecdote.  My son was traveling in Texas and was coming back from a city on the Labor Day weekend in a modest-sized — it was Bush's home, where he used to live, in Midland, Texas.  And on the afternoon plane, there were 15 children who were lined up, young children, five or six years old, who were traveling to be with another parent.  That's a well-known phenomenon.

What was tragic is that the Southwest Airlines attendant who's trying to get them on the plane makes a public announcement to say, "Will the parents of these children" who are told by the airline not to leave the airport until the plane takes off — "would you please come back to check in your children?"  The families had just dumped the children and left them. 

So here all these five- or six-year old children waiting to get on an airplane, and the divorced parents — I don't know which one — you know, which parent they were staying with at this point.  I presume since it's during the week it's the primary caregivers — wouldn't even stay long enough to help the children get on the things.  That does not give me the confidence that you have expressed about the solution to this problem.

I don't see how you can — I don't see how any thinking person can say, "Unless the United States Government, with money from taxes, gets involved in health care to do this, that anybody is going to take care of it."  It is happening right now.  I mean, I take care of the poor, and I'm telling you there is — you know, somebody has to pay somebody to do it, by and large, even in the papers. 

Even if you take it in your own home, you're paying somebody to do that.  I take care of quite a few people who have, you know, a disabled person from cancer, and so forth and so on.  It's not the wife or the husband who is taking care of them.  He or she is still working.  It's some — it's one of these women, health care people at minimum wage come in there and work for the hospice, or whatever.

So what I don't — it seems like to me that you're making an appeal for sort of a — to use Peter's term, sort of a revival of caring, and I don't think that's going — maybe I'm misinterpreting you, but I think — I don't see how you can get away from the fact that this has to be an economically solved problem. 

I mean, every day I deal with people who can't get health care until they're dying.  Every single day.  You know, we take — we don't take health care as a right.  It's a right if you have the money to pay for it, like shelter and food and so forth.  If you have the money, you can get it.  But if you don't, you can't. 

So tell me where I'm wrong about this.  I still don't think it's going to help to write a paper to say we ought to be kind and love one another, and that children ought to take care of their parents.

PROF. DRESSER:  Dan, I think you're making the case of why a group like ours could usefully present this whole complex of unprecedented problems in their fullness. 

They are — you're right, they're being discussed to death in a very shallow way.  But it seems to me there is a value in naming the question, in naming the problems — let's put the S on it — in naming and pointing out that this is upon us one way or the other, and it hasn't been adequately publicly discussed.

CHAIRMAN KASS:  Let's continue this discussion.  Gil, Robby, Peter.  I'll put myself in the queue as well.

PROF. MEILAENDER:  I'd like to think out loud a little bit about what the problem actually is.  It seems to me that we have a lot of things floating around here, and it's no — I sympathize with your desire to figure out what exactly we're supposed to put our finger on.

In one way we have a demographic problem.  In another way we have a cultural problem.  Peter and Mary Ann seem agreed that it's not just demographic; it's cultural.  I'm not sure how deep the agreement — I mean, I sometimes think Mary Ann thinks the cultural problem is produced by the demographics, and Peter thinks that the cultural problem is produced by something kind of very deep in us, or something.  I don't know.

But, okay, Diana and Jim have a certain amount of confidence in our ability to muddle through and deal with the problems, at least if we understand it demographically. 

I think there are two ways to state the problem.  One way of stating it, and I think, Dan, this is sort of what you have in mind when you say you see no possible solution other than, you know, government providing the resources needed — one way to state it is to say that there are going to be a lot of frail, dependent people who need care.  And they have to have it provided for them.

Another way to think about the problem, which I think must pick up the kind of cultural issue more, is to say there are a going to be a lot of frail, dependent people who need care, and they'd like to get it in certain ways from certain people.  That's a different problem.

If you think about the beginning of life, children, there are other ways to raise children other than in families.  There are even possibly more efficient ways to do it.  You know, you just parcel them out to responsible adults to do it.  We don't do that, because we think that certain kinds of attachments are important.

Well, similarly here, I'm sympathetic to the kind of we'll muddle — the government will help us to muddle through if the question is simply, will we find some way to provide care for these people?  Though I'm a little worried when the payer has an extraordinary interest in controlling the costs.

But, still, it goes much deeper, though, and I'm not sure that I see too much in Peter's or in Mary Ann's papers that help me to solve it.  It goes much deeper if the question is:  how do you deal with the fact that I really don't just want to be cared for when I'm old?  I want to be cared for by certain people who are attached to me in certain ways, and so forth.  And I guess I'd rather be cared for by anybody than not cared for at all if it comes down to that.

But I don't think that's what we want.  And if that's the deeper problem, then it is harder to say how we'll get at it.  But it's not just an economic matter.  I mean, it's obviously an economic matter, but it's not just an economic matter.  And I took at least part of what Mary Ann's and Peter's papers were getting at — was to try to push toward — you know, whether they want to say it the way I've said it, I don't know, but at least towards some sense like that.

CHAIRMAN KASS:  Diana, quickly, then to Gil.

DR. SCHAUB:  Yes.  I just want to ask Gil a question.  Do you see the white paper as addressing that at all?  I mean, the RAND paper talks about this new class of patients and a different sort of care that would need to be provided for them, and it talks, you know, fairly extensively about the need for home health care workers and the training of those people and, you know, aid to families who want to take on these burdens.  I mean, it seems to me that that sketches the kinds of policy prescriptions that might help families, you know, assume these burdens that they want to assume.

PROF. MEILAENDER:  I think at least to some degree it has that in mind.  That's right.  And it suggests a way that government may, in fact, be able to support and sustain that larger cultural sphere.  So, sure, I think to some degree that's possible.

CHAIRMAN KASS:  Robby George?

PROF. GEORGE:  Well, I certainly agree with Dan that we should be principled, but also disciplined and practical about the problems that we decide to take on.  But I think I'm a little more optimistic, Dan, than you are about our opportunity here to make a contribution to an important issue.

Let me reinforce just a couple of things that Gil and Mary Ann said, and maybe say it a little differently.  It might not be any more persuasive to you when they're said differently, but let me give it a shot.  There's a demographic issue here.  We all know about it.  Part of Dan's concern is that it's such a big — an amorphous issue that we could waste a lot of time just rolling around in the muddle of it.

But the reality is, with an aging population, in part made possible by the wonderful life extension that your profession has given us as a great gift, the reality is that the demographic problem is going to be addressed. 

It's going to be addressed by government.  It's going to be addressed in terms of public policy.  And there are going to be plenty of people who have a piece of that problem, and who will address it — who will need to address it and who will address it who are going to think about it essentially in cost-benefit terms, in a very — perhaps in a different sense than what we might like, a very pragmatic way.

Now, there should be somewhere somebody thinking about the dimensions of the problem that are not reducible to cost-benefit analysis, including those dimensions of the problem which raise the question of whether we can have — and, if so, what is the character of unchosen obligations — obligations to people by virtue of familial relationship, by virtue of being fellow citizens.  There are a range of dimensions to this.

There is an academic literature on unchosen obligations, and even some academic literature on the application of principles pertaining to unchosen applications to social problems like the demographic problem that we have.  But it's merely an academic literature, and I don't know of anyone in the public policy domain — perhaps I'm just ignorant of what's going on, but I — I personally don't know of anyone in the public policy domain who is doing much on this issue, certainly as it pertains to the demographic problem. 

So I think if we don't do it, probably nobody will, at least nobody will anytime soon.  But in the meantime, the cost-benefit analyzers will proceed forward on this.

Now, that doesn't mean that we can solve the whole problem by any means, but I think we can grab a little piece of it.  And the way we'll do that, if we decide to do it and if we do it well, is not by immediately identifying the question, but by trying to understand the problem in its breadth well enough that we can identify the smaller parts of it that would lend themselves to formulation in terms of discrete and answerable questions, but questions that aren't answerable in cost-benefit analysis terms and questions that are — whose answers will be controversial. 

And we probably all won't agree, and we certainly won't be able to persuade all of our fellow citizens about them.  But, nevertheless, there are dimensions here that need to be addressed in other than cost-benefit terms.  And if we don't do it, I don't think anybody else will.

Now, this I think relates to what Gil said about not only wanting to be cared for but wanting to be cared for by certain people on certain terms and in certain ways.  On that, it seems to me that we should have in mind that public policy really does shape culture.  Of course it is also shaped by culture, but there's a mutuality here, and part of that picture is that public policy shapes culture. 

So somebody ought to worry about the impact of proposed public policies on our understanding of, for example, unchosen obligations.  Someone ought to think about the dangers of public policy that is based exclusively or almost exclusively on cost-benefit analysis, for institutions like the institution of the family.

This is not to prejudge what the answer will be, given the real-life constraints that you've put your — you've called to our attention, Dan.  I'm not trying to prejudge this at all, and I don't think Mary Ann was trying to prejudge it by saying we need to bring back a culture that used to be.

But whatever we do in public policy in this country, it will have a culture-shaping impact.  And while we can't predict perfectly what that will be with any particular policy proposal, we can at least think about it and get a reasonable idea of what the likely consequences are, reasonable enough to make a judgment about whether we would recommend that the Congress of the United States or that the government or the states go down that road.

So what I hope we would do is, in a disciplined way, go forward with what we're going, looking at the problem broadly as we have been, but with a view to narrowing down those parts of the problem, narrowing down to those parts of the problem, our focus to those parts of the problem where we can actually make an impact as an ethics council, where we're not simply concerned about economics or cost-benefit analysis, but the human dimensions of the problem that aren't reducible to those terms.

CHAIRMAN KASS:  Let me join in here, too, and — this is part of not just a private conversation between Dan and me that I don't expect you yet to have satisfaction on this.  And until you're satisfied, we all have more work to do, so I welcome the challenge.

With respect to some of the particular, more narrow focused questions, I think the subsequent sessions, and especially the ones tomorrow, should satisfy you.  On the question of to what extent should the presence of advanced dementia count in making decisions about what kinds of medical interventions for secondary medical problems — that's a major topic already.  It's only going to get worse.

Do the traditional ethical ways of thinking about that — are they sufficient?  Or do we have to rethink those matters?  That was a challenge Robert Binstock posed to us as something we should take up.  I think it's an important issue, and Bo Burt is going to address specifically certain kinds of public policy recommendations relevant to this topic.

Without being defensive, however, and not — hoping I don't simply reiterate what's been said, it does seem to me that we do have an opportunity to offer a real diagnosis here beyond the obvious demographic and economic facts.  Is there, in fact, a "crisis" in long-term care?  And what does that mean?

And to describe it in such a way that might, in fact, prevent people who have an impulse simply to go in there and fix — to fix it in a way that, in fact, could aggravate the question — aggravate the difficulty. 

Jim Wilson's comment about Europe should be taken very, very seriously.  The degree to which people come to regard it not as their business but as the society's (by means of the government's) business to care for those who are in need of care, the degree to which people come to believe that, and the degree to which government moves in there to satisfy that belief, might very well contribute to the diminution of the attitude of caring.

Now, it seems to me we have out there in the public discussion of these matters — and this is too superficial and it won't be, won't capture everybody — but on the one hand you have the libertarians and the economic conservatives.  They say, "Look, this is a market problem."  When the demand rises and there are enough of the baby boomers, and they've got more money than people have had before, they will find a way to pay for the care that they need. 

They will make a choice whether they should work and pay somebody else to care for Pop, or they'll take the time off and care for him.  But that's — it's a free choice like everything else, and the market will adjust because it — supply will meet the demand.

On the other hand, there are people who — and I don't want to attribute a whole view to you from what you've just said.  There are other people who say, "Look, there's no way in the world the market is going to solve this problem." This is part and parcel of a massive health care crisis in this country.  And unless the government steps in as — if not just for safety net reasons, at least for safety net purposes, it's to step forward and deal with this thing, we simply — people will not get the care they deserve, not only at the end of life but throughout their life.

Both of those solutions, notwithstanding their large differences, treat this thing really as primarily a question of resources and manpower.  And yet it has been said repeatedly around here, because these are questions of relations amongst the generations and not simply the tending of bodies, it does seem to me how the society chooses to formulate what it takes the problem to be will make a difference to how we proceed to debate it.

And it may very well be that the dimensions of the problem are so great that we should stop worrying about caring about the dependent and simply care for them and get the best possible caregivers whether they actually are caring in a feeling sense the way family members are.  Maybe that's the right way to go.

But it seems to me very important that we think through what it is that people actually want and hope for here, and what it is that we as individuals and as a community, who have children to support and parents to care for, and soon many of us are going to be in that spot ourselves, how do we want to define this problem as a society? 

I think just as the Reproduction andRresponsibility report issued in some recommendations at the end — but the bulk of that document was diagnostic and an attempt to diagnose a problem in a way in which it hadn't been comprehensively diagnosed before.  Similarly, it seems to me what Mary Ann has called for here is an invitation to diagnose this problem beyond saying there are lots of these people and we should be kind to them.

Peter has given at least a reason to think that part of the diagnosis will make certain kinds of solutions or certain kinds of approaches very difficult, but at least it would be worthwhile being mindful of it. 

Now, it seems to me that the question for this session is:  how adequate is our diagnosis of this particular alleged crisis or impending problem?  I'll try to make one small contribution to that discussion.

The attempt to assimilate this to the health care crisis is understandable, health care coverage and things of that sort.  But it's — a lot of these people who are — especially 40 percent of us are destined for a slow, lingering death of enfeeblement and dementia. 

It's not clear that those are the sorts of things for which the medical system, as it has been traditionally set up, is really — it doesn't seem to be exactly a health care problem as much as it seems to be a problem of human care and that — they have medical problems to be sure.  But if you define it fundamentally as a medical problem, then you're going to be looking for a medically-based solution only.

And Diana — Joanne Lynn's attempt, really, to take — to sort of smuggle the large question of the long-term care of the people who are a little loopy and who are in decline, under the end of life medical care problem is an attempt to try to take advantage of the fact that the country cares about medicine but doesn't really care about caring — I mean, as a matter of policy, caring for those people who don't have acute medical problems that you can diagnose.

Now, it seems to me if that intuition is right, somehow beginning to define this problem in a more concrete and thorough way might be a contribution to the way in which the community as a whole will come to debate these things, even if we don't have a particular policy recommendation on the cultural question.

I think you're right that we should find some more manageable things as well, and I'm hoping that the next sessions will be on a narrower topic.  But here I think the — Mary Ann says, "Look, there's a looming crisis, a long-term care crisis."  Is that true? 

And if so, how should you describe it in such a way that you're thinking about it in a sound way before you go about designing — trying to design policies or programs that might make it better or that might try to make it better but in fact make it worse, if, in fact, they sap the energy of people to give the care that, in fact, the old and the dependent want and need.

Now, I think that came out — I don't know if it's persuasive.  I think I said what I was hoping I would say. 

Rebecca?

PROF. DRESSER:  First, an anecdote to defend Sweden.  My sister's mother-in-law just died, and her three children were quite involved in trying to help her through that, and dealing with all sorts of care issues.  And so to what — to the degree that it's a deterrent to family involvement, it wasn't in that case.

One set of questions, one way to approach this would be to try to take a Rawlsian approach and say — we don't even have to be under the "veil of ignorance."  We could just think about what would a just system look like?  What kinds of choices should be out there?  What kinds of services?

I think David Shenk did a good job of writing about the suffering that's out there now, the way that people are struggling with this very patchwork system.  And we — I think we tend to deal with it as individuals, and it's fortuitous.  We think, oh, I'm lucky, you know, my parents are doing well.  And, you know, God forbid, I get into that situation.  And I think that's largely how we handle child care, too.  It's, well, you put together your own crazy arrangement, and that's what you do.

Are there things that we'd like to see that would be different?  And also, what would be defensible expectations for someone like Gil?  I think we'll get into that in the next session, but what is he — what is defensible for him to expect in terms of the kind of care he wants?  What is defensible for children to say in terms of, you know, I — you're important to me, but I have other projects, too, and I have my own children.

So I think those are very much the topics of ethical inquiry, appropriately.  And they have to do with biology and mortality, so I think they're bioethical issues.

DR. FOSTER:  I just want to make one statement about which — every one of us sitting around this table is going to be okay.  All right?  I mean, I've got — most of us have enough money, and we have it intact.  We're going to be okay.  Okay? 

So we can't sit around this knowing that we're going to be okay.  I mean, I'm sure my children will take care of me.  If they don't, I have enough money that I'll get taken care of anyway.  But there are vast numbers of people in the world, which I deal with every single day, that don't have that option.  So we need to be careful about saying, "Well, how are we going to deal with — you know, with Gil's problem, and so forth?"  I mean, it's much deeper than that.

And if you — and it's also medical.  I mean, one of the things we're going to talk about — the average person who comes in from the nursing home with Alzheimer's, and so forth — and our hospital has five to six different diseases that we deal with.  So to say that it's not a medical problem is — is beyond belief.  I mean, it's part of —

CHAIRMAN KASS:  No.  I corrected myself in the middle, Dan.  They have secondary medical problems.

DR. FOSTER:  Yes.

CHAIRMAN KASS:  But —

DR. FOSTER:  We just have to be careful as being upper middle class people to think that what happens to us is what's happening to the nation or to the world.

PROF. MEILAENDER:  I'm expecting all of you to care for me.

(Laughter.)

DR. FOSTER:  And your poor old body, Gil.

(Laughter.)

CHAIRMAN KASS:  Ben?

DR. CARSON:  I think we have to also recognize the fact that there are different definitions of who the elderly are, because things have changed very significantly in the last couple of decades in terms of who is elderly.

You know, when I was a kid, you know, when you were 50 you were elderly.  Now you're a spring chicken at 50.  And a lot of it also has to do with the state of health.  You know, Alan Greenspan is 78 years old, but, you know, he is healthy, he's active, he's doing a lot of things.  So I think that has to go into the equation.

Also, because we have the ability to keep elderly people going now for long periods of time, even though there may be significant quality of life issues, as Dan was just bringing up, should we do it?  I mean, I think, you know, as we're advancing in our medical knowledge, you know, we have the ability to extend people's lives very, very significantly.

And I think one of the questions that has to be addressed on a national level is:  where do we draw the line?  Which set of diseases or combination of diseases, what quality of life, you know — or is it just arbitrary, and do people just get to choose on their own, you know, "I've been, you know, completely devoid of any mental faculties for 10 years, but want to be kept alive regardless of anything that comes down the pike."

I'm just wondering if maybe we oughtn't to be discussing some of those issues.

CHAIRMAN KASS:  Charles?

DR. KRAUTHAMMER:  I'd like to address Dan's objections and difficulties with this issue.  You were talking, Dan, about how ultimately we know what the problem is, or there is a big problem out there that we all agree upon, largely demographic and ultimately economic.  And we know that ultimately we're going to have to deal with it by taxes, by having people help.  We're not going to recreate a culture.

I think that's true, but I think what we can do as a Council, and as people who have at least the leisure of having a little bit of time to look at it before the crisis hits, is to look at the unintended cultural consequences of economic solutions.  At least to start thinking about them before they happen.

When you were talking about ultimately we're going to have to use our taxes and help these people, I was thinking about the fate of the AFDC program — welfare — which was founded for the most humane of reasons, as a way to help widows and orphans, and who could be against that? 

And then, as there were cultural changes happening in the '60s and '70s, we kept it going because why would you want to decrease aid to widows — to single women, ultimately, and children at a time when their numbers were increasing.  And then, in the mid '80s and '90s, we realized that we had unintentionally helped to accelerate the disintegration of families and created a system designed to encourage single motherhood, with all of the consequent cultural catastrophes attendant to it.

So we abolished it, and in a spirited debate in the mid '90s in which there were all kinds of predictions about how we would have this incredible rise in suffering, and then when it didn't happen people attributed all that to the economic boom of the '90s, but then the recession set in, and, in fact, that catastrophe hasn't happened.

And, in essence, the abolition of AFDC has had a remarkable, small yes, but a remarkable effect, at least statistically, in arresting certain cultural events, cultural trends.  So looking at that experience, which I think your reference to using our taxes and ultimately having to help these older folks triggered this, here was a model which occurred 50, 60 years ago, people did not think through the unintended cultural effects of these programs. 

I think as other people who are almost exclusively looking at cost and benefit, almost exclusively looking at the economic way to approach it, and economic results, I think one thing that we can contribute is to look at the possible cultural effects and to anticipate them before we embark on the programs which you look at and which most people looking at assume inevitably is going to have to be a government affais, is going to have to be an affair treated economically, and it's going to have to be ultimately supported by taxes.

So it's a modest thing that we can do, but I think at least it's something and it's worthwhile as a beginning in thinking about what we can contribute.

CHAIRMAN KASS:  Mary Ann?

PROF. GLENDON:  So we still have this problem of naming and diagnosis.  And it seems to me that to think of the problem as a crisis in long-term care is too specific.  I think we really have to start with a more general demarcation of the area of problems — that is, the challenges that are facing an aging society. 

It is a confluence of demographic events that have brought us into a place that the human race has never known before.  It is the increase in longevity, the lower birth rate, and the changing roles of women, in combination, that have produced a whole range of problems, of which the crisis in long-term care is but one.

So that would be a stab at how we would present what we're talking about.  Then, I think because we're all — I think a test of whether there's anything here is whether we can get Dan to move at all.  So I'm going to make one more stab at it.

Dan, one way to think about it would be, so what happens if we — if the country just muddles through, hoping that we will be able to take care of these problems as they arise through immigration or through various kinds of government programs? 

I think very predictably two things will happen, and with all the caveats about comparisons to Europe.  Nevertheless, Europe is already there, and their experience shows us two things.  One is that if you view this problem as a problem of competition for scarce resources, you are going to have conflict between the elderly and the people who would prefer to have government take care of the elderly on the one hand.  That's one group.

And the young poor families in our society on the other, and it would be desirable if there is some way to replace that conflict with the idea that we're all in this together and we have to solve that problem together.  So there's one set of predictable consequences if we just try to muddle through.

The other is more sinister, but you can see in Europe, as the economic crunch becomes heavier and heavier, and the conflict model prevails, that it's going to be tough times for the weakest and the most vulnerable.  And so Dr. Carson raised these really hard, serious, important questions.  We don't want to get careless about answering those questions.  We want to give them the serious attention they deserve.

So I would say the most striking part of the white paper was calling to our attention something we don't like to think about, that 40 percent of us are facing long periods of disability.  This is something new.  A hundred years ago pneumonia carried people off.  This is something new.  We don't have experience to tell us how to deal with it. 

And at the same time we're dealing with that, we have fewer childful — is that a word?  Child-producing families in our society than ever before.  And immigrants aren't going to make up for it.  They'll delay it.  It won't be — the crisis will not descend on us as quickly as it has on Europe, but it will come.

DR. FOSTER:  Well, let me just comment about my immovability, and I'm listening carefully.  But I was once accused by some medical students, because I had written an editorial in The New England Journal of Medicine where I said that the level of the blood glucose did not relate to the complications of diabetes, you know, with blindness, and so forth and so on.

And then, subsequently I had changed my mind.  They said, "Well, Dr. Foster, why did you change your mind?"  And this is a statement that I always say.  When the evidence changes, I change.  Okay?  So, and when the evidence doesn't change, then I don't change, whether that's medical or otherwise.

And a big study was done that showed that the editorial that I had written was at the time correct, but subsequently in a massive study of the effect of glucose showed that we were wrong, because we didn't have enough data to do it.  So I'm listening carefully to see if there's any evidence that would persuade me that I am wrong in my position.

Can we muddle through?  I mean, I'm perfectly — I was on the Dallas School Board.  I know perfectly what Charles was talking about and the detrimental effects of some public policies that we take.  The health care in Britain, and so forth, I mean, has in many ways — or Canada has in many ways been flawed.  I'm talking about the single payer things.  They're not good systems in one sense.

But they're better systems than having 40 million people who can't get any care at all, I think, and that's — so I'm perfectly willing also to look at the things.  But I'm just — I only want to say that when the — I will — I am listening very carefully, Mary Ann, even if I don't show it.  Okay?

CHAIRMAN KASS:  To help provide more evidence, could we return to the way properly chastened by Dan's admonition, to the original question, which was:  to what extent do we have an adequate terminology and an adequate diagnosis of this problem?  We've got just about a few more minutes in this session.

But, I mean, what do we think about the way in which this problem has been presented by Mary Ann, with Peter's cautious — is that a hand?

DR. LAWLER:  Robby George, a little while ago, used the phrase "unchosen obligation."  But under our law, I think there is no such thing as an unchosen obligation right now.  So I have every confidence in the world that Gil's children will care for him if he falls in the 40 percent, if he's lucky enough to fall in the 40 percent and nothing else gets him first.

On the other hand, they don't have to.  They can — anything might happen under our law, because our law is becoming progressively more choice-constituted, progressively more individualistic.  But our whole system depends upon people taking unchosen obligation seriously anyway.  People think of themselves some of the time not as individuals.  People think of themselves some of the time as children.

And even a standpoint some of the time citizens have — if there's a vacuum, then government ought to step in.   But it's not self-evident to me it would be the best thing if government stepped in.  If government steps in, it means there sort of is a cultural problem, because individuals are not — people — Americans aren't doing what they have always done in the past, so to speak.

And it's also unreasonable to believe that any economic solution could solve the problem, or, in fact, you could only make the problem worse — our inability to talk well to make sense out of the tough phrase "unchosen obligation."  So if we were to go around the room and talk about what unchosen obligation means to me, we would have a number of different and conflicting answers.

Nonetheless, Professor Binstock said last time — I actually looked into this — a billion and one studies show that the whole future of our health care system depends upon Americans taking the idea of unchosen obligation seriously.  And so maybe we can take it seriously.

DR. FOSTER:  Could I just make one, and then I'm through for the evening, for the day.  The other — we've talked about these economic issues, and everybody wants to talk about the cultural issues.  But one of the other things that's going on in our country right now, it's not only the already uninsured, is that every company that is struggling with economic survival is cutting pensions and retirement.  And so what we're seeing is our small businesses don't give health insurance or retirement.

So you've got a drastic — unless something amazing happens to our economy, the middle class people are not going to have any money — you know, it's $30- or $40,000 a year right now if you have to be in an institution, or you have somebody around the clock in a home.  Many places — $50,000.  Not many people in their retirement even now have $50,000. 

But if you have your retirement cut — I mean, it's not just the airlines.  It's in every — every business is cutting the benefits to their employees, and that's another risk that is under the economic rubric that makes me think that that is such a central part of the problem.

CHAIRMAN KASS:  Let me ask you this, Dan.  Just taking a possible — thinking about down the road to possible policy recommendations that might be offered here, do you think it makes a difference, speaking now both as a clinician and as a man who has been around a number of decades, do you think it matters whether we think about building large nursing homes for people with dementia, or whether we choose instead to reimburse home nursing, providing care in the homes?

In other words, is the way in which one sort of thinks about the — and, obviously, there can be different solutions for different people at different stages.  But if you really see this as, let's say, society's attempt and an act of solidarity to stand with people who do not have their resources, it matters a lot which of the possible — which of the possible alternatives we offer, and which ones we would recommend depends partly on questions of feasibility but also partly in terms of the goals that one would like to be supporting.

Do you think it's out of the question that in days of fractured families, fewer children, many people are going to get to old age and have no children whatsoever to expect to have, you know, these — what was the — unchosen obligation.  Do you, nevertheless, think that we should make every effort to support families in their ability to care for their own?  Or do we want to say the community will care for it; it ceases to be any particular group of people's obligations locally?

DR. FOSTER:  I said I wasn't going to say anything more.  I would much prefer a system, an economic system from the government that would place health care workers in the home and for the family as opposed to building more buildings.  Now, if you're comatose and, you know, you're going to have to be taken care of 24 hours a day, sucked out and turned to keep from decubituses, you just can't do that, even with — you know, with — because we're not even talking about LPNs. 

I mean, we're talking about people who have been maids before, you know, who come in and oftentimes form, you know, very close relationships with families.  I think that's a very important way that would help conserve some of the other things that people have.  So if you ask me, "Do I want to build more nursing homes, or would I prefer to have people being able to come home?" the latter overwhelmingly, but that's — I don't know which will be economically more expensive or cheaper.

CHAIRMAN KASS:  Okay.  Diana?

DR. SCHAUB:  But both what Charles mentioned, speaking about the unintended cultural consequences of economy policies, and what you're talking about now would require talking very much in terms of policy prescriptions and trying to make predictions about the results of specific policies.

CHAIRMAN KASS:  Indeed.

DR. SCHAUB:  And it seems to me that would be — well, I don't know, somewhat different than the broadening of the framework of discussion approach.

CHAIRMAN KASS:  Yes.  No, I was using that as an example to try to indicate that when one came down to the question of policy, and one would, of course, try to think about the unintended consequences of doing A rather than B, I was teasing out from Dan a certain intuition that he has both as a physician and as a human being about what the desirable nexus of care would be, other things being equal and without exaggeration. 

And that depends — what that means to me is that he has, whether articulated or not, a certain tacit understanding of both what the dilemmas are and what the more desirable alternatives are.  And I think it's very important that those tacit understandings be made conscious and explicit, that it — that Dan, in other words, is interested, as I think most people in this room would be, and not only for themselves but as much as possible for as many of our fellow citizens, that they should not simply be cared for in the sense of tended to, but in places where people actually care, because they still remain connected, notwithstanding their diminished status.

Now, it may be economically infeasible to do that, but before one simply adopts the economic solution — if I could just repeat myself — it would be nice to have that firmly in mind, that one doesn't want to pull the rug out from under that in unintended ways.

Charles?

DR. KRAUTHAMMER:  Mary Ann asked how we might sort of — what we might call this issue.  I think what we're looking at is we might call it the economic and cultural consequences of the adult-centered society, and I like her formulation.  It's not just care for outsiders.  It's what happens when the median age of a society is rising?  It's attention, the center of gravity, all the political weight is in people of increasingly rising age.  What happens?

It's an extremely interesting question.  On the economic issues, I think we could be more policy-oriented because obviously a lot of work has been done.  On the cultural, I think we would have to be more speculative and sort of cautionary, saying, "If you do X, it might have a cultural effect."

But I just want to throw in one datum, which is I was just reading a paper by Nick Eberstadt on infertility in the Western world, and it is astonishing.  He points out what we really often overlook.  The United States is the only advanced industrial country anywhere that is maintaining — has got a replacement rate for its population, and it isn't only immigration, although it puts us way over the top. 

He points out that if you take it away, we're about — we're between 2.0 and 2.1, which is essentially replacement, whereas the average in Europe is 1.4, which is catastrophic.  It means that you lose a third of the population every generation. 

So the interesting effect of that is that we have a laboratory.  We in America have a real cushion.  We do have a crisis approaching, but it is approaching slowly.  It's slouching towards us.  It's not crashing in on us.  It's crashing in on Europe, and we have the advantage of looking at what is happening in Europe, where it's happening at an unbelievably rapid rate — median age is rising by — you know, dramatically, and really unprecedentedly.

Here it's going to happen a lot slower, because we are replacing our population, and we are incredibly agile and experienced at absorbing immigrants.  So we have a cushion.  Even though it's going to be a problem, it's still — it's not a year or two away.  It's a decade or two or three away.

And using the laboratory of Europe and East Asia, interestingly, which is also in demographic collapse, we can learn a lot about the economic effects and the cultural effects, which are far more subtle.

So I'd suggest as part of this inquiry we could use or get experts like Nick and others who have looked at this and can talk about what's happening in Europe today, East Asia today, and that would inform us.  It would not be all speculation.  It would tell us what really happens when the median age jumped from 20 to 40 within a generation.

CHAIRMAN KASS:  Last comment by Robby, and we'll take a break.

PROF. GEORGE:  Well, I forget who said it, but it's true that disagreement is a very hard thing to reach.  The trouble is in discussions and debates of this nature, people very frequently talk past each other, and they think they are disagreeing, but sometimes they are in what my friend Hadley Arkes calls "heated agreement."

So I'm not sure whether we've managed to reach disagreement yet, or to some extent we've talked past each other.  So let me take a little stock.  Please correct me, Dan and others, if I'm wrong in this stock taking.  There is an enormous demographic problem having to do with aging, and the aging of the population, life extension, birth dearth, and so forth.  And this problem has enormous economic consequences and bears very heavily on people at the lower end of the socioeconomic spectrum.

I think everybody is agreed about that.  I think also everybody agrees that it's a societal imperative, it's an ethical imperative, that we do our best to come up with a system, whether that system tends to be more market-oriented or more social democratic, but some sort of solution to the problem, to the extent that problems like this can be solved or at least managed, that comes to the aid, especially of those who are most in need, which is not people like ourselves around the table but a lot of other people in the country and in the world.

Okay.  Agreed.  Now, some of us have been also pressing the point that in thinking about the problem we ought to be aware that thinking about it in cost-benefit terms, or purely economic terms, will mean neglecting ethical issues which arise by virtue of the fact that any proposed policy solution or managing — management of the problem will have effects, some of which are not obvious, some of which are probably utterly unpredictable, but not — probably many of which are at least not obvious, and they're worth thinking about.

And that if we think about them, we have to think about them in light of ethical concerns we have about what kind of culture is a good culture for human beings to live in. 

I don't think, Dan — correct me if I'm wrong.  I don't think that you are quarreling with that, just as we're not quarreling with the proposition that this is an economic problem that bears very heavily on the poor and has to be thought about in those terms.

But if that's right, then where is the disagreement?  We're not economists.  We can't solve the economic problem.  But we know that we have to think about the ethical issues in light of different possible economic solutions ranging from the more social democratic to the more market-oriented.

Are we not putting enough emphasis on the economic side?  Are we failing to see that the economic solution really is more obvious than I think it is, or that some of us at least think it is?  And that if we focused on it properly, we would see that we can eliminate some of the possibilities on that spectrum from the social democratic to the more market-oriented, and that a truly — a sound concern about ethics would be focused on narrowing those options to the ones that seem to you to be the right ones?  Or where are we?  Do we disagree?

CHAIRMAN KASS:  Could I speak on his behalf, since we've talked about this at length?  If you'll allow me.  And if I don't do you justice —

DR. FOSTER:   You'd do it anyway, so I have to allow you.

CHAIRMAN KASS:  No, I wouldn't.  I wouldn't do it anyway.  I wouldn't do it.

He was very careful at the beginning.  It was not, is this an enormous problem?  The question is:  is this an enormous problem that this Council can say something useful about as opposed to simply wring our hands and saying, "This is an enormous problem, and it would be nice if we could do something about it."

He's a practically-minded fellow, at least as — in many respects, but as a member of this body, it may be that he might want something in which we are able to say yeah or nay, but at the very least to say something about which people won't say, "That's nice.  They met.  They talked.  They worried.  They wrote.  So what?" 

And I think it's absolutely salutary for the President's Council on Metaphysics to take such admonitions and challenges to heart.  It would not be enough for us to simply have an interesting conversation.  If we can diagnose the problem in such a way that helps people actually think concretely about how to make it better, I'm fairly confident if Dan saw that we were able to do that he wouldn't mind.  But he hadn't yet — at least at the beginning of this session, hadn't yet seen that we have done that or are sufficiently far enough on the way to make him satisfied with that.

As my client, did your attorney do a good enough job?

DR. FOSTER:  Yes.  I thought Robby's summary was very good.  What I've tried to say, and it may — and you pointed out — is, I just want to have — I'm not against ethics or against morals or against wishing the culture of the nation was better and trying to work — I just want to do it, as you say, in a way which might have some impact rather than just writing a report that somebody might read and say that — okay, that they sat around and did it, that there ought to be something that could be defined by questions. 

I mean, one of the things that Ben and you talked about, and we're going to talk about tomorrow, is what are the limits, for example, in health care in terms of the economy.  So, yes, I'm — that's a — you did a very good job for me.

PROF. GEORGE:  Can I ask either counsel or the client one question?  Just to be perfectly clear.  Is Dan — Dan, are you asking for us to make specific policy recommendations?  Or would it satisfy the concerns, as Leon has articulated them, that we have raised concerns — if in the end this is what we do — raise concerns about ethically significant issues having to do with the unintended consequences of proposed solutions to the economic dimensions of the problem.

If it were the latter, would that be a disappointment to you?

DR. FOSTER:  No.  I mean, our previous experience in terms of enhancement did not result in any sort of policy decisions.  Our decision as we came along, in terms of stem cell, resulted in policy recommendations.  So it might be yes or it might be no.  I just don't want us to muddle around. 

I mean, I think we ought to say what we're going to do to see if we could be helpful.  That's all I care about.  If it should, and our time is short — maybe very short, depending on, you know, whatever happens with the elections.  Either way, you know, but — but we don't have time, as Charles said, to do all of the economics. 

I mean, the best people in the world are thinking about this, you know, and so we — but we might come to a conclusion about an approach that Leon posed to me about enhancing care for the elderly in homes when the family does not exist anymore that would help — to help personalize it and maybe have tenderness and love there as well.

So the answer is, no, it would not mean that I was out of it if we didn't have a policy decision on that, no.

CHAIRMAN KASS:  Let's take 15 minutes.  We'll return to allow Gil Meilaender to be a burden to all his friends.

(Laughter.)

(Whereupon, the proceedings in the foregoing matter went off the record at 3:37 p.m. and went back on the record at 4:00 p.m.)

SESSION 4: AGING AND CARE-GIVING: REFLECTIONS ON THE BURDEN OF CARE

CHAIRMAN KASS: For the rest of this meeting, we turn from the topic of neuroscience, brain, and behavior, to questions having to do with aging, dementia, caregiving, and society — a series of topics that have a certain internal coherence to them.  I think the coherence — I don't have to lay it out, but I think we will see what it is as we go through it.

I remind you, since there are some people who wonder where the ethical issues are in all of this, that among the first responsibilities of this Council, as enunciated in the Executive Order, is that we should conduct fundamental inquiry into the human and ethical significance of advances in biomedical science and technology.

And while there is no particular technological innovation here whose ethical significance or human significance we are looking at, we are, in a way, looking at the human and ethical significance of the aggregate effects of every successful biomedical science and technology, which, amongst its great blessings, has produced a healthy human population into the '60s and '70s and '80s in an unprecedented way.

But as a possible cost of that success, we have the human significance of a growing population that is increasingly aged, and a population in which, although many people are healthier for a lot longer, most of us have to look forward to a protracted period of decline and debility in need to care. 

And it seems appropriate for this Council to look into this question and to try to lift it up to public view, if it can find the right means of doing so. 

We started two meetings ago very modestly with a little paper by Gil that explored the question of the concept of a demented person, and a discussion led by Rebecca on the limits of advanced directives — very small, modest beginnings. 

The last time we broadened the scope very widely, beginning with two views of the aging society: A social science view with Robert Binstock talking about Social Security, Medicare, and various related matters, and offering, in fact, a couple of challenges for this Council, one of which we will take up tomorrow. 

And Thomas Cole's sort of review of the meaning of aging and old age in modern American society, and raising for us what he takes to be the major cultural question, namely some kind of doubt about what it actually means to be old and especially infirmed in today's world, absent the kind of iconographic — the kind of coherent views of the life cycle to which his life iconography pointed us for previous ages.

We had a very fine presentation from Dr. Selkoe on the research in Alzheimer's Disease, and a companion presentation from David Shenk on some of the travails of having and caring for people with Alzheimer's Disease, and then a rather thorough treatment of the dilemmas of the caregivers, familial and institutional, from Geri Hall.

And that's where we were last time, and the question was:  how could we follow up that sort of broad discussion to try to produce certain kinds of greater focus?  In the sessions after this one, we will take up certain particular ethical matters, questions of the ethical attitudes of the old and soon to be old and dependent toward their beloved young descendants, and then the very difficult question about medical intervention in the presence of severe, moderately severe, severe Alzheimer's Disease, triggered by a fine paper by Eric Cohen presented — we'll talk about tomorrow.

And then we will have a public policy session with Robert Burt's presentation in the second session tomorrow.  The first session is, in a way, the broadest and to some extent least concretely focused.  But I think that that's not inappropriate.  After the last meeting, Mary Ann Glendon suggested that one of the things the Council might do would be pick up the suggestions made by Robert Binstock and others at the last meeting that we really are on the threshold of a large crisis in long-term care in this country.

And it would be important for the Council at least to explore the degree to which this is so, and to try to understand both its character, its dimensions, and its underlying causes.  And one could raise this question — if we were to proceed, really, in the spirit of trying to have a general diagnosis of this question, is this mainly demographic?  An economic problem?  Coupled with the failure of medicine to do adequately, to somehow eliminate the need for such care? 

Or is this also a cultural or ethical or spiritual one as suggested in part by Thomas Cole?  And if it is the latter, to what extent does our tendency to treat it largely as an economic and demographic matter aggravate those aspects of it that might, in fact, be matters of culture?  Are we concerned in the sense of caring for the aged and the dependent? 

Are we interested in just caring for them — that is to say, meeting their needs?  Or do we have a stake in caring about them and caring for them, not simply as needy creatures but as people still connected with us, full members of the community?

We have several papers that are in the briefing book that are intended to trigger this kind of discussion — a discussion of how well do we understand the difficulties that we face in coming to grips with the need to care for those needing our — needing care in the coming Geriatric Society, not just the people with Alzheimer's, but people with other kinds of severe dependencies that make it impossible for them to look after themselves.

Joanne Lynn's paper, not really presented as a long-term care problem, she treats it as end-of-life care.  But because she presents end of life as possibly lasting a very long time, in fact, she has I think successfully smuggled the long-term care issue under the rubric of how you deal with people at the end of life.  And there are several striking things in that paper that I hope you noticed and we can refer to it as we wish.

Mary Ann has written a very short paper, kind of a synoptic view, calling attention to what she thinks is the dimension of this question as well as some of its critical features.  And Peter Lawler has written a kind of cultural commentary, trying to point out as to why, if insofar as we're talking not just about economics and demography, but about the cultural, ethical, and spiritual need to care about and not just for why we face certain kinds of difficulties in — given our cultural predilections that he outlines there.

That I think is to set the table for a discussion which will go where it will.  I've asked a couple of people if they might be prepared to offer beginning comments, and let me start with Diana Schaub.

DR. SCHAUB:  Leon asked me if I would be willing to start the conversation off this session.  But I confess I don't know what to think after reading the three essays assigned for the session.

Mary Ann Glendon tells us that a caregiving crisis will soon be upon us, a result of living longer, propagating less, and sending women off to work.  She suggests that the Council could do some good, not by dealing in policy prescriptions but simply by sounding the toxin and sounding it in such a way as to broaden the framework for discussion.

I don't know whether Peter Lawler broadens the discussion, but he certainly deepens it.  We learned that the caregiving crisis is not just a result of demographic shifts, shortages of women power and money.  It's more profoundly a crisis of our culture.  We find ourselves increasingly in need of care, and increasingly unlikely to be cared for. 

This is the predictable — and Peter seems to suggest inevitable — result of our individualism, which devalues care as a fundamentally unproductive activity.  In seeking to live carefree as radically, self-sufficient individuals, we are destined to live without proper care in our ever-lengthening periods of great need. 

The only true solutions that Peter speaks of for those with Alzheimer's being at home with large families, or attended to by the Sisters of Mercy, are, as he admits, solutions that are evaporating.  His is a grim diagnosis.  If he's right, then our condition is irremediable, inoperable.  We can understand it, but we can't do much about it.  Peter does not suggest that Americans could ever become more welcoming of either giving or receiving care.

Mary Ann spoke of the need to cultivate a certain tragic sensibility.  Peter digs deep into that dark ground. 

The third paper, the white paper from RAND, takes a very different approach.  It has a very American can-do spirit about it.  The authors speak not of a crisis but of a new set of challenges — challenges that lots of folks are already thinking about and addressing through a growing body of research and certain pioneering programs.

The authors deliver the good news.  We can adapt and reform our health care system.  We've done so before.  The hospice movement of the last few decades was a response to an earlier shift in the needs of the sick.  With the prevalence of cancer, a new class of patients emerged — the terminally ill and dying. 

The authors state that what we need now is a new movement to respond to the emergence of yet another class of patients — the declining, the frail, the demented.  This movement would combine curative and palliative aspects in their proper and ever-shifting measure.  Treatment would focus more on the various needs of the patient, less on medical diagnosis.

So the white paper gives a number of concrete suggestions as to how this tailoring of services to needs might be accomplished.  It sketches a cure for the ills of caregiving. 

I just have a couple of questions and a couple of observations.  To the extent that the crisis or challenge is demographic, is it also temporary?  Is it just a matter of seeing the boomers through to a decent exit?  I realize that many of the trends will continue — longer life, fewer children, women working, and perhaps our fundamental orientation towards individualism will continue.

But will those things all be more manageable once the boomers have passed, or not?  This particular generation, of which I am a tail end member, has always caused consternation to society by virtue of its numbers and by virtue of its character.  As it moves through life, it wrenches all thought and energy and resources to its concerns.

So I'm actually not too worried that we will fail to pay attention to the elderly boomers.  They've always been vocal and insistent about their interests.  They've also been inventive.  I suspect that they will change the shape of retirement.  It will be less retiring, but there will still come a time when the young old become the old old.

And I guess at that point I put somewhat more faith in the cash nexus and the laws of supply and demand than Peter does.  When the demand is there, wages will rise, workers will come.  Many of them will probably be immigrants, not fully acculturated to American individualism, and so maybe wiser about the ways of caring.

Caregiving as a calling may be superior to caregiving as a profession.  But that shouldn't prevent us from doing all we can to raise the standing of the profession and to attract into it those with a true calling.

Finally, I want to quarrel just a bit with a point that both Mary Ann and Peter make.  They both refer to our individualism-induced obtuseness or obliviousness.  Mary Ann speaks of how we tend to relegate obvious facts about human dependency to the margins of consciousness.  Peters says that more than ever before we experience ourselves simply as individuals.

And yet, whatever our declared views, we in fact lead care-filled lives.  Our careless language is not reflective of our care-full lives.  And they both — they do acknowledge this.  Mary Ann says it's still a fact that almost all persons spend most of their lives either as dependents or caring for dependents.  And Peter acknowledges that almost everyone today is some mixture of productive individual and loving caregiver. 

The wisdom of women about the sources of human happiness in the ends of life is now accessible to men, just as the productive knowledge of men is now accessible to women.  That doesn't seem to me to be a bad basis for devising public policies that support private life.  It may also be why the coming challenges are not more widely perceived as a crisis.  It's just the way of things.  We know our parents are aging, and we know that we will be there soon also.

Alexis de Tocqueville, an author that I know Peter knows very well, wrote about the detrimental effects of individualism.  But he also wrote of the uniquely American doctrine, which he calls "self-interest rightly understood," that counteracted the worst effects of individualism.  Tocqueville describes how an enlightened self-interest constantly brings Americans to aid each other and disposes them willingly to sacrifice a part of their time and wealth.

We clearly have a long-term interest in long-term care.  As Mary Ann says, if the outlook for dependents is grim, the outlook for everyone is grim.  Reflection on ourselves could spur improved care for others. 

Tocqueville also notes that frequently Americans are better even than their self-regarding doctrine.  They are capable of pure generosity.  On occasion, they care for others, not only because they believe it redounds to their own advantage, but out of the goodness of their hearts. 

So I guess I'm suggesting that we have some resources with which to meet the coming crisis — the much maligned cash nexus, our Tocquevillian self-interest rightly understood, and small but inexpungable reserves of human love and generosity.

CHAIRMAN KASS: Thank you.

Someone else with — Jim Wilson?

PROF. WILSON:  I would like to expand a bit on what Diana said.  I hadn't been aware of her views, but they correspond very closely with my own.  I think in trying to think about our responsibility to care for older people, we run a risk in this country from drawing our generalizations about this country from what we know of this country in its present state.

I think we would be well advised to look more broadly, and if someone wishes to pursue this issue we ought to look more broadly.  Let me give you one bit of data that illustrates the problem.  The survey is 10 or 15 years old, long before we began to worry earnestly about the retiring baby boomers, but I think it suggests a striking difference.

In the same year, survey analysts asked a representative sample of Swedes and a representative sample of Americans the following question:  who do you think should care for older people?  Two-thirds of Americans said, "Their children."  Eleven percent of Swedes said, "Their children."

Now, I suspect, without drawing too much significance to this study, that we could array the countries of the world along a spectrum from those who make the natural assumption that the children are caregivers to those who make the natural assumption that the bureaucracy or someone else or the government is responsible.

Now, the United States may be moving along this spectrum, but the survey, to the best of my knowledge, has not been repeated.  So I do not know whether we've moved very much.

Let me end as Diane started by speculating on some of the reasons why, just using this survey, Americans are a more caregiving people than our friends in Sweden.  And I suspect our friends in several other European countries.

It's not simply enlightened interest — a self-interest rightly understood.  It's the religious basis of self-interest rightly understood, about which Tocqueville also spoke.  This is the most religious industrialized country in the world, and I think the impact of religion on care is profound, both institutionally, because churches and synagogues get involved in it, and indirectly because churches and synagogues reinforce that belief among their members.

I think the second reason is we have a relatively weak welfare state.  We did not immediately follow Otto von Bismarck's suggestion made to defeat his liberal opponents in Prussia at the time he made it.  We did not follow the British experience.

And most of my colleagues in social science regularly reproach us for not having a bigger and fatter welfare state.  That may be a good or a bad criticism, but one of the consequences of it is is that we rely on each other more, because we are not confident that the welfare state will make a difference.  Indeed, a great majority of young people, when polled, say they do not believe Social Security will be there for them when they retire.  I think they're wrong, though it may be there in somewhat different form.

And the third reason is that this is a country, unlike other countries, of family-oriented immigrants.  Not all immigrants come here with families, and some who come here go back to the country of origin. 

But if you look at the Asians and Latinos who do come here, you discover they come here with a family orientation which produces two happy things for us — a large supply of younger people, some of whom can be hired to do work we do not wish to do for ourselves, but, much more importantly, a belief that family responsibility is critical.

These are thoughts off the top of my head, and each — and perhaps all may be disproved by deeper inquiry.  But my general point is, do not generalize about what the United States is like by making excessive generalizations about our individualism.

CHAIRMAN KASS: Peter?

DR. LAWLER:  Let me degeneralize a bit.  I wrote the paper to be provocative, but, in general, I agree with Professor Wilson that what makes America different from a raw statistical point of view — and I'm not a statistics guy — it would be evangelicals and immigrants.

For example, I read an article in The Washington Post last week written by some guy from the New American Century, whose name I don't remember right now, and it said something like this.  That if it weren't for people who regularly went to church, our birth rate would be about the same as France.  This is the key variable.  Which would mean that, in fact, my paper is full of exaggerations, and the exaggerations would be along these lines. 

I said Americans experience themselves more as individuals than ever before, and I'm sticking with that.  But I didn't say Americans experience themselves always as individuals, because if that were the case we would be monstrously unhappy all the time.  We're individuals when we pursue happiness, but when we actually are happy we're something else — creatures, family members, friends, citizens, neighbors, whatever.

So there has always been that great American mixture described by Tocqueville that we're individuals part of the week, not individuals the rest of the week, and this is actually a pretty good solution.  But it's a solution that in some ways is intrinsically unstable, although I perfectly agree with Diana that we will never individualize love out of existence or anything like that.

So if what makes America different is we have immigrants who are family-oriented, we also notice that lasts for a generation or two, that birth rates in immigrant groups drop off after they're here for a generation or two.  But in terms of experience ourselves, say, as creatures, America is the land of religious revival.  And so the story of Europe may have been the story of constant religious decline, culminating in some post-religious era. 

That is not at all the story of America, and so in a full, non-generalized account of America right now, we would have to include that fact.  So I'm sticking with the we're more individual than ever before.  I didn't mean to say we were individuals and nothing more.  I just wanted to say that as we become more individualist, caregiving becomes a dilemma for us. 

But I also say in the paper that we're not really individuals all the time, because if we really were to think about this, we would kind of then destroy the non-producing class, and none of us wants to do that.  And so as typically middle class people, we're caught between being individuals and not individuals, and so the average American in a middle class family wants to care for his or her parents.  Who can deny that?

On the other hand, wants to be productive.  There is a conflict in the life, and it's — the conflict is getting progressively more difficult.  So I didn't mean to be, although I probably was, as doom and gloom as Diana said.  I don't want to be so deep that I'm not optimistic in some respects.

I have some faith in the cash nexus, but not all that much.  I do have, to say it the corny, old-fashioned way, somewhat more faith in the human soul, and not only the American soul finally.

CHAIRMAN KASS: Dan?

DR. FOSTER:  It may be too early to say this, but — and Leon and I have talked about this before.  My concern about this topic is not that there's a problem.  It's been predicted for a very long time — and there are many people looking at it from the RAND Corporation to anything else.

The question I want to see — I want to be answered about or to have us come to an answer about is rather than just saying, well, we need to talk about the ethics of the aging population, is to ask ourselves, what question are we really asking?  I don't think you can do anything if you don't have a question that is susceptible to discussion and answer, rather than a generalization that almost everybody who works in the world knows about already.

And, I mean, I just don't think it — we're going to be very helpful to say, well, we ought to be kind to our parents, or we ought to do this, that, or the other.  They're either some real questions or they're not, and that's what I've been struggling with. 

When we started out on the stem cell, we had a real question.  Yes or no.  Yes or no.  I can't see what it is that we want to do, and I think we're going to be wasting our time if we just keep hearing reports about how many elderly there are and what their problems are and what dementia does for it, and so forth.

Now, you could be precise.  You could say, well, okay, let's look and see how we might deal with this problem if we were looking at policy or the government.  That would be something that you could look at. 

You talk about the diminishing birthrate in France.  What France does is they now have — you know, everybody can have a — that has a baby can have a good place to get them cared for, so that the mother can still go back to work, and so forth.  There are social solutions to this if you want to pay enough money to do it, and you could say, "Well, we want to do that."

I mean, I think everybody agrees, if you just read the newspapers, that we are not replenishing young people who are workers.  You saw The New York Times about Pittsburgh, how they couldn't replace the mill workers, and so forth and so on, there. 

Well, if you're going to do that, then you have to give the incentives to women in a new age that they can be maternal, and they can go into medicine or science or law or whatever and have their children taken care of well without having to sacrifice their — that would be an approach that you could say would be a specific thing that you could look at.

But what I'm worried about is just muddling around in generalizations that, in the end, that nobody is going to pay any attention to, or is likely not to pay any attention to. 

Now, I know from Leon's letter that I am a very marked minority in terms of this Council.  I mean, he says that there are lots of people who think we ought to do this.  Well, how many times are we going to listen to the fact that — you know, that a caregiver for a person with Alzheimer's Disease, and so forth, is going to sacrifice things?  You can't be productive or whatever.

So I just want to throw it open early on, and almost like this being we were talking at lunch today about, you know, sometimes maybe we needed Executive Sessions to just hammer this through. 

But what I would like to be convinced of is that at the end of this discussion, we do something that everybody believes is meaningful, that's answered — several specific things.  They are very big topics, if you're talking about spending more money, you know, for health care and for long-term care, and so forth.  I mean, it's — maybe we don't have the expertise to do that, but that's what I would like to hear. 

I mean, I don't — I don't want to sound mean or anything, because I've — you know, I mean, I know about taking care of dependents, and so forth.  But I just want to have — I really want to know what is the question we're going to address?  Or questions, if there are more.  And how will we make something worthwhile out of it, which is not only meaningful to us but meaningful elsewhere?

Some of you have read the Nature article that just came out, which I thought was a very — an assessment of our Council.  And one of the criticisms was, which was an unfair criticism because we were called into organization to address specifically the biomedical things and the stem cell things.  That's what we were told.

But we were criticized because we never addressed the big problems of ethics, of bioethics, you know, like health care, and so forth.  I thought that was — was true, but not — it was unfair in the sense that that's not how we were constructed.

But this, to me, is worrisome, because I can't see — and I've tried to think about it a lot since at the last meeting when Leon and I talked about it.  I'm trying to find myself saying, okay, you have a free feel.  Give us a question that you think that would be good for us to address, because I'm not smart enough to come up with a question or questions. 

I'd really like that to be a subject of this general discussion this afternoon.  What is it, specifically and in hard-nosed fashion, that we hope to accomplish and answer?  Mary Ann is already after me, so that's —

PROF. GLENDON:  Do we have to think in terms of a specific question?  This really goes to the nature of what we do here as a Council.  Are we supposed to think in terms of a specific question?  Or is it enough to note that the society is facing a set of challenges that are, in several ways, unprecedented? 

And that if — if they continue to be discussed within the framework that Alan Greenspan, again, warning for the second time this year on the problems of the Social Security system, if they continue to be addressed simply within an economic framework, decisions are going to be made about caregiving, about dependency in our society, that will affect all of us, young and old, without consideration of the non-economic dimensions.

So it seems to me that it's not likely — democracies, as Tocqueville taught us, are not very good at thinking about the long term for a whole lot of reasons.  It seems to me one of the services that a body like ours can perform is to think a little bit about the long term. 

One aspect of this whole problem that makes it unprecedented is something we haven't talked about yet, and that is the elderly are not the only dependents in our society.  There's the problem with who is going to care for the very young.  And one thing that happens, that predictably will happen in an aging society, is there are going to be fewer and fewer children. 

This is not only an economic problem for the labor force; it's a problem for how we think about the very long — out of sight, out of mind.  We are increasingly becoming a very adult-centered society.  Turn on your television.  Look at MTV and you'll see what I mean.  The more we become an aging society, the more we become an adult-centered society, the more we have to worry about children and child-raising families who are now in a minority.

So without framing a precise question, I do think that there are dimensions of this demographic phenomenon that are — the reason we care about them is that they are cultural.  It's not just a demographic problem.  It's not just an economic problem.  The aging of the society is going to affect our culture, what kind of society we become, in ways that are hard to foresee. 

And if we just lurch along and treat it as an economic problem, we may end up in an America that is not the place that all of us hoped and dreamed it would be.  That's a little start.

DR. FOSTER:  Well, let me answer first.  I did try to put an S on the question to questions.  I don't know that there's one thing.  I certainly agree with you in terms of the problem, not just economically, of children.  The estimates are that at the end of this decade 60 percent of children in this country are from one family — you know, one-parent families. 

There are not going to be families available here — even in this very religious country, there are not going to be families to take care of people.  And what that means is that we have to punt the care to somebody who is not family, in my own view.  So I can see no exit from this at all, either in terms of the child care, and so forth, to enhance the birthrate in this country, to the care at the end, because the traditional care, I don't believe, is going to be there.

Let me just give you a little anecdote.  My son was traveling in Texas and was coming back from a city on the Labor Day weekend in a modest-sized — it was Bush's home, where he used to live, in Midland, Texas.  And on the afternoon plane, there were 15 children who were lined up, young children, five or six years old, who were traveling to be with another parent.  That's a well-known phenomenon.

What was tragic is that the Southwest Airlines attendant who's trying to get them on the plane makes a public announcement to say, "Will the parents of these children" who are told by the airline not to leave the airport until the plane takes off — "would you please come back to check in your children?"  The families had just dumped the children and left them. 

So here all these five- or six-year old children waiting to get on an airplane, and the divorced parents — I don't know which one — you know, which parent they were staying with at this point.  I presume since it's during the week it's the primary caregivers — wouldn't even stay long enough to help the children get on the things.  That does not give me the confidence that you have expressed about the solution to this problem.

I don't see how you can — I don't see how any thinking person can say, "Unless the United States Government, with money from taxes, gets involved in health care to do this, that anybody is going to take care of it."  It is happening right now.  I mean, I take care of the poor, and I'm telling you there is — you know, somebody has to pay somebody to do it, by and large, even in the papers. 

Even if you take it in your own home, you're paying somebody to do that.  I take care of quite a few people who have, you know, a disabled person from cancer, and so forth and so on.  It's not the wife or the husband who is taking care of them.  He or she is still working.  It's some — it's one of these women, health care people at minimum wage come in there and work for the hospice, or whatever.

So what I don't — it seems like to me that you're making an appeal for sort of a — to use Peter's term, sort of a revival of caring, and I don't think that's going — maybe I'm misinterpreting you, but I think — I don't see how you can get away from the fact that this has to be an economically solved problem. 

I mean, every day I deal with people who can't get health care until they're dying.  Every single day.  You know, we take — we don't take health care as a right.  It's a right if you have the money to pay for it, like shelter and food and so forth.  If you have the money, you can get it.  But if you don't, you can't. 

So tell me where I'm wrong about this.  I still don't think it's going to help to write a paper to say we ought to be kind and love one another, and that children ought to take care of their parents.

PROF. DRESSER:  Dan, I think you're making the case of why a group like ours could usefully present this whole complex of unprecedented problems in their fullness. 

They are — you're right, they're being discussed to death in a very shallow way.  But it seems to me there is a value in naming the question, in naming the problems — let's put the S on it — in naming and pointing out that this is upon us one way or the other, and it hasn't been adequately publicly discussed.

CHAIRMAN KASS: Let's continue this discussion.  Gil, Robby, Peter.  I'll put myself in the queue as well.

PROF. MEILAENDER:  I'd like to think out loud a little bit about what the problem actually is.  It seems to me that we have a lot of things floating around here, and it's no — I sympathize with your desire to figure out what exactly we're supposed to put our finger on.

In one way we have a demographic problem.  In another way we have a cultural problem.  Peter and Mary Ann seem agreed that it's not just demographic; it's cultural.  I'm not sure how deep the agreement — I mean, I sometimes think Mary Ann thinks the cultural problem is produced by the demographics, and Peter thinks that the cultural problem is produced by something kind of very deep in us, or something.  I don't know.

But, okay, Diana and Jim have a certain amount of confidence in our ability to muddle through and deal with the problems, at least if we understand it demographically. 

I think there are two ways to state the problem.  One way of stating it, and I think, Dan, this is sort of what you have in mind when you say you see no possible solution other than, you know, government providing the resources needed — one way to state it is to say that there are going to be a lot of frail, dependent people who need care.  And they have to have it provided for them.

Another way to think about the problem, which I think must pick up the kind of cultural issue more, is to say there are a going to be a lot of frail, dependent people who need care, and they'd like to get it in certain ways from certain people.  That's a different problem.

If you think about the beginning of life, children, there are other ways to raise children other than in families.  There are even possibly more efficient ways to do it.  You know, you just parcel them out to responsible adults to do it.  We don't do that, because we think that certain kinds of attachments are important.

Well, similarly here, I'm sympathetic to the kind of we'll muddle — the government will help us to muddle through if the question is simply, will we find some way to provide care for these people?  Though I'm a little worried when the payer has an extraordinary interest in controlling the costs.

But, still, it goes much deeper, though, and I'm not sure that I see too much in Peter's or in Mary Ann's papers that help me to solve it.  It goes much deeper if the question is:  how do you deal with the fact that I really don't just want to be cared for when I'm old?  I want to be cared for by certain people who are attached to me in certain ways, and so forth.  And I guess I'd rather be cared for by anybody than not cared for at all if it comes down to that.

But I don't think that's what we want.  And if that's the deeper problem, then it is harder to say how we'll get at it.  But it's not just an economic matter.  I mean, it's obviously an economic matter, but it's not just an economic matter.  And I took at least part of what Mary Ann's and Peter's papers were getting at — was to try to push toward — you know, whether they want to say it the way I've said it, I don't know, but at least towards some sense like that.

CHAIRMAN KASS: Diana, quickly, then to Gil.

DR. SCHAUB:  Yes.  I just want to ask Gil a question.  Do you see the white paper as addressing that at all?  I mean, the RAND paper talks about this new class of patients and a different sort of care that would need to be provided for them, and it talks, you know, fairly extensively about the need for home health care workers and the training of those people and, you know, aid to families who want to take on these burdens.  I mean, it seems to me that that sketches the kinds of policy prescriptions that might help families, you know, assume these burdens that they want to assume.

PROF. MEILAENDER:  I think at least to some degree it has that in mind.  That's right.  And it suggests a way that government may, in fact, be able to support and sustain that larger cultural sphere.  So, sure, I think to some degree that's possible.

CHAIRMAN KASS: Robby George?

PROF. GEORGE:  Well, I certainly agree with Dan that we should be principled, but also disciplined and practical about the problems that we decide to take on.  But I think I'm a little more optimistic, Dan, than you are about our opportunity here to make a contribution to an important issue.

Let me reinforce just a couple of things that Gil and Mary Ann said, and maybe say it a little differently.  It might not be any more persuasive to you when they're said differently, but let me give it a shot.  There's a demographic issue here.  We all know about it.  Part of Dan's concern is that it's such a big — an amorphous issue that we could waste a lot of time just rolling around in the muddle of it.

But the reality is, with an aging population, in part made possible by the wonderful life extension that your profession has given us as a great gift, the reality is that the demographic problem is going to be addressed. 

It's going to be addressed by government.  It's going to be addressed in terms of public policy.  And there are going to be plenty of people who have a piece of that problem, and who will address it — who will need to address it and who will address it who are going to think about it essentially in cost-benefit terms, in a very — perhaps in a different sense than what we might like, a very pragmatic way.

Now, there should be somewhere somebody thinking about the dimensions of the problem that are not reducible to cost-benefit analysis, including those dimensions of the problem which raise the question of whether we can have — and, if so, what is the character of unchosen obligations — obligations to people by virtue of familial relationship, by virtue of being fellow citizens.  There are a range of dimensions to this.

There is an academic literature on unchosen obligations, and even some academic literature on the application of principles pertaining to unchosen applications to social problems like the demographic problem that we have.  But it's merely an academic literature, and I don't know of anyone in the public policy domain — perhaps I'm just ignorant of what's going on, but I — I personally don't know of anyone in the public policy domain who is doing much on this issue, certainly as it pertains to the demographic problem. 

So I think if we don't do it, probably nobody will, at least nobody will anytime soon.  But in the meantime, the cost-benefit analyzers will proceed forward on this.

Now, that doesn't mean that we can solve the whole problem by any means, but I think we can grab a little piece of it.  And the way we'll do that, if we decide to do it and if we do it well, is not by immediately identifying the question, but by trying to understand the problem in its breadth well enough that we can identify the smaller parts of it that would lend themselves to formulation in terms of discrete and answerable questions, but questions that aren't answerable in cost-benefit analysis terms and questions that are — whose answers will be controversial. 

And we probably all won't agree, and we certainly won't be able to persuade all of our fellow citizens about them.  But, nevertheless, there are dimensions here that need to be addressed in other than cost-benefit terms.  And if we don't do it, I don't think anybody else will.

Now, this I think relates to what Gil said about not only wanting to be cared for but wanting to be cared for by certain people on certain terms and in certain ways.  On that, it seems to me that we should have in mind that public policy really does shape culture.  Of course it is also shaped by culture, but there's a mutuality here, and part of that picture is that public policy shapes culture. 

So somebody ought to worry about the impact of proposed public policies on our understanding of, for example, unchosen obligations.  Someone ought to think about the dangers of public policy that is based exclusively or almost exclusively on cost-benefit analysis, for institutions like the institution of the family.

This is not to prejudge what the answer will be, given the real-life constraints that you've put your — you've called to our attention, Dan.  I'm not trying to prejudge this at all, and I don't think Mary Ann was trying to prejudge it by saying we need to bring back a culture that used to be.

But whatever we do in public policy in this country, it will have a culture-shaping impact.  And while we can't predict perfectly what that will be with any particular policy proposal, we can at least think about it and get a reasonable idea of what the likely consequences are, reasonable enough to make a judgment about whether we would recommend that the Congress of the United States or that the government or the states go down that road.

So what I hope we would do is, in a disciplined way, go forward with what we're going, looking at the problem broadly as we have been, but with a view to narrowing down those parts of the problem, narrowing down to those parts of the problem, our focus to those parts of the problem where we can actually make an impact as an ethics council, where we're not simply concerned about economics or cost-benefit analysis, but the human dimensions of the problem that aren't reducible to those terms.

CHAIRMAN KASS: Let me join in here, too, and — this is part of not just a private conversation between Dan and me that I don't expect you yet to have satisfaction on this.  And until you're satisfied, we all have more work to do, so I welcome the challenge.

With respect to some of the particular, more narrow focused questions, I think the subsequent sessions, and especially the ones tomorrow, should satisfy you.  On the question of to what extent should the presence of advanced dementia count in making decisions about what kinds of medical interventions for secondary medical problems — that's a major topic already.  It's only going to get worse.

Do the traditional ethical ways of thinking about that — are they sufficient?  Or do we have to rethink those matters?  That was a challenge Robert Binstock posed to us as something we should take up.  I think it's an important issue, and Bo Burke is going to address specifically certain kinds of public policy recommendations relevant to this topic.

Without being defensive, however, and not — hoping I don't simply reiterate what's been said, it does seem to me that we do have an opportunity to offer a real diagnosis here beyond the obvious demographic and economic facts.  Is there, in fact, a "crisis" in long-term care?  And what does that mean?

And to describe it in such a way that might, in fact, prevent people who have an impulse simply to go in there and fix — to fix it in a way that, in fact, could aggravate the question — aggravate the difficulty. 

Jim Wilson's comment about Europe should be taken very, very seriously.  The degree to which people come to regard it not as their business but as the society by means of the government's business to care for those who are in need of care, the degree to which people come to believe that, and the degree to which government moves in there to satisfy that belief, might very well contribute to the diminution of the attitude of caring.

Now, it seems to me we have out there in the public discussion of these matters — and this is too superficial and it won't be — won't capture everybody, but on the one hand you have the libertarians and the economic conservatives.  They say, "Look, this is a market problem."  When the demand rises and there are enough of the baby boomers, and they've got more money than people have had before, they will find a way to pay for the care that they need. 

They will make a choice whether they should work and pay somebody else to care for Pop, or they'll take the time off and care for them.  But that's — it's a free choice like everything else, and the market will adjust because it — supply will meet the demand.

On the other hand, there are people who — and I don't want to attribute a whole view to you from what you've just said.  There are other people who say, "Look, there's no way in the world the market is going to solve this problem."

This is part and parcel of a massive health care crisis in this country.  And unless the government steps in as — if not just for safety net reasons, at least for safety net purposes, it's to step forward and deal with this thing, we simply — people will not get the care they deserve, not only at the end of life but throughout their life.

Both of those solutions, notwithstanding their large differences, treat this thing really as primarily a question of resources and manpower.  And yet it has been said repeatedly around here, because these are questions of correlations amongst the generations and not simply the tending of bodies, it does seem to me how the society chooses to formulate what it takes the problem to be will make a difference to how they proceed to debate it.

And it may very well be that the dimensions of the problem are so great that we should stop worrying about caring about the dependent and simply care for them and get the best possible caregivers whether they actually are caring in a feeling sense the way family members are.  Maybe that's the right way to go.

But it seems to me very important that we sort of think through what it is that people actually want and hope for here, and what it is that we as individuals and as a community, who have children to support and parents to care for, and soon many of us are going to be in that spot ourselves, how do we want to define this problem as a society? 

I think just as the reproduction and responsibility report issued in some recommendations at the end — but the bulk of that document was diagnostic and an attempt to diagnose a problem in a way in which it hadn't been comprehensively diagnosed before.  Similarly, it seems to me what Mary Ann has called for here is an invitation to diagnose this problem beyond saying there are lots of these people and we should be kind to them.

Peter has given at least a reason to think that part of the diagnosis will make certain kinds of solutions or certain kinds of approaches very difficult, but at least it would be worthwhile being mindful of it. 

Now, it seems to me that the question for this session is:  how adequate is our diagnosis of this particular alleged crisis or impending problem?  I'll try to make one small contribution to that discussion.

The attempt to assimilate this to the health care crisis is understandable, health care coverage and things of that sort.  But it's — a lot of these people who are — especially 40 percent of us are destined for a slow, lingering death of enfeeblement and dementia. 

It's not clear that those are the sorts of things for which the medical system, as it has been traditionally set up, is really — it doesn't seem to be exactly a health care problem as much as it seems to be a problem of human care and that — they have medical problems to be sure.  But if you define it fundamentally as a medical problem, then you're going to be looking for a medically-based solution only.

And Diana — Joanne Lynn's attempt, really, to take — to sort of smuggle the large question of the long-term care of the people who are a little loopy and who are in decline, under the end of life medical care problem is an attempt to try to take advantage of the fact that the country cares about medicine but doesn't really care about caring — I mean, as a matter of policy, caring for those people who don't have acute medical problems that you can diagnose.

Now, it seems to me if that intuition is right, somehow beginning to define this problem in a more concrete and thorough way might be a contribution to the way in which the community as a whole will come to debate these things, even if we don't have a particular policy recommendation on the cultural question.

I think you're right that we should find some more manageable things as well, and I'm hoping that the next sessions will be on a narrower topic.  But here I think the — Mary Ann says, "Look, there's a looming crisis, a long-term care crisis."  Is that true? 

And if so, how should you describe it in such a way that you're thinking about it in a sound way before you go about designing — trying to design policies or programs that might make it better or that might try to make it better but in fact make it worse, if, in fact, they sap the energy of people to give the care that, in fact, the old and the dependent want and need.

Now, I think that came out — I don't know if it's persuasive.  I think I said what I was hoping I would say. 

Rebecca?

PROF. DRESSER:  First, an anecdote to defend Sweden.  My sister's mother-in-law just died, and her three children were quite involved in trying to help her through that, and dealing with all sorts of care issues.  And so to what — to the degree that it's a deterrent to family involvement, it wasn't in that case.

One set of questions, one way to approach this would be to try to take a Rawlsian approach and say — we don't even have to be under the "veil of ignorance."  We could just think about what would a just system look like?  What kinds of choices should be out there?  What kinds of services?

I think David Shenk did a good job of writing about the suffering that's out there now, the way that people are struggling with this very patchwork system.  And we — I think we tend to deal with it as individuals, and it's fortuitous.  We think, oh, I'm lucky, you know, my parents are doing well.  And, you know, God forbid, I get into that situation.  And I think that's largely how we handle child care, too.  It's, well, you put together your own crazy arrangement, and that's what you do.

Are there things that we'd like to see that would be different?  And also, what would be defensible expectations for someone like Gil?  I think we'll get into that in the next session, but what is he — what is defensible for him to expect in terms of the kind of care he wants?  What is defensible for children to say in terms of, you know, I — you're important to me, but I have other projects, too, and I have my own children.

So I think those are very much the topics of ethical inquiry, appropriately.  And they have to do with biology and mortality, so I think they're bioethical issues.

DR. FOSTER:  I just want to make one statement about which — every one of us sitting around this table is going to be okay.  All right?  I mean, I've got — most of us have enough money, and we have it intact.  We're going to be okay.  Okay? 

So we can't sit around this knowing that we're going to be okay.  I mean, I'm sure my children will take care of me.  If they don't, I have enough money that I'll get taken care of anyway.  But there are vast numbers of people in the world, which I deal with every single day, that don't have that option.  So we need to be careful about saying, "Well, how are we going to deal with — you know, with Gil's problem, and so forth?"  I mean, it's much deeper than that.

And if you — and it's also medical.  I mean, one of the things we're going to talk about — the average person who comes in from the nursing home with Alzheimer's, and so forth — and our hospital has five to six different diseases that we deal with.  So to say that it's not a medical problem is — is beyond belief.  I mean, it's part of —

CHAIRMAN KASS: No.  I corrected myself in the middle, Dan.  They have secondary medical problems.

DR. FOSTER:  Yes.

CHAIRMAN KASS: But —

DR. FOSTER:  We just have to be careful as being upper middle class people to think that what happens to us is what's happening to the nation or to the world.

PROF. MEILAENDER:  I'm expecting all of you to care for me.

(Laughter.)

DR. FOSTER:  And your poor old body, Gil.

(Laughter.)

CHAIRMAN KASS: Ben?

DR. CARSON:  I think we have to also recognize the fact that there are different definitions of who the elderly are, because things have changed very significantly in the last couple of decades in terms of who is elderly.

You know, when I was a kid, you know, when you were 50 you were elderly.  Now you're a spring chicken at 50.  And a lot of it also has to do with the state of health.  You know, Alan Greenspan is 78 years old, but, you know, he is healthy, he's active, he's doing a lot of things.  So I think that has to go into the equation.

Also, because we have the ability to keep elderly people going now for long periods of time, even though there may be significant quality of life issues, as Dan was just bringing up, should we do it?  I mean, I think, you know, as we're advancing in our medical knowledge, you know, we have the ability to extend people's lives very, very significantly.

And I think one of the questions that has to be addressed on a national level is:  where do we draw the line?  Which set of diseases or combination of diseases, what quality of life, you know — or is it just arbitrary, and do people just get to choose on their own, you know, "I've been, you know, completely devoid of any mental faculties for 10 years, but want to be kept alive regardless of anything that comes down the pike."

I'm just wondering if maybe we oughtn't to be discussing some of those issues.

CHAIRMAN KASS: Charles?

DR. KRAUTHAMMER:  I'd like to address Dan's objections and difficulties with this issue.  You were talking, Dan, about how ultimately we know what the problem is, or there is a big problem out there that we all agree upon, largely demographic and ultimately economic.  And we know that ultimately we're going to have to deal with it by taxes, by having people help.  We're not going to recreate a culture.

I think that's true, but I think what we can do as a Council, and as people who have at least the leisure of having a little bit of time to look at it before the crisis hits, is to look at the unintended cultural consequences of economic solutions.  At least to start thinking about them before they happen.

When you were talking about ultimately we're going to have to use our taxes and help these people, I was thinking about the fate of the AFDC program — welfare — which was founded for the most humane of reasons, as a way to help widows and orphans, and who could be against that? 

And then, as there were cultural changes happening in the '60s and '70s, we kept it going because why would you want to decrease aid to widows — to single women, ultimately, and children at a time when their numbers were increasing.  And then, in the mid '80s and '90s, we realized that we had unintentionally helped to accelerate the disintegration of families and created a system designed to encourage single motherhood, with all of the consequent cultural catastrophes attendant to it.

So we abolished it, and in a spirited debate in the mid '90s in which there were all kinds of predictions about how we would have this incredible rise in suffering, and then when it didn't happen people attributed all that to the economic boom of the '90s, but then the recession set in, and, in fact, that catastrophe hasn't happened.

And, in essence, the abolition of AFDC has had a remarkable, small yes, but a remarkable effect, at least statistically, in arresting certain cultural events, cultural trends.  So looking at that experience, which I think your reference to using our taxes and ultimately having to help these older folks triggered this, here was a model which occurred 50, 60 years ago, people did not think through the unintended cultural effects of these programs. 

I think as other people who are almost exclusively looking at cost and benefit, almost exclusively looking at the economic way to approach it, and economic results, I think one thing that we can contribute is to look at the possible cultural effects and to anticipate them before we embark on the programs which you look at and which most people looking at assume inevitably is going to have to be a government affais, is going to have to be an affair treated economically, and it's going to have to be ultimately supported by taxes.

So it's a modest thing that we can do, but I think at least it's something and it's worthwhile as a beginning in thinking about what we can contribute.

CHAIRMAN KASS: Mary Ann?

PROF. GLENDON:  So we still have this problem of naming and diagnosis.  And it seems to me that to think of the problem as a crisis in long-term care is too specific.  I think we really have to start with a more general demarcation of the area of problems — that is, the challenges that are facing an aging society. 

It is a confluence of demographic events that have brought us into a place that the human race has never known before.  It is the increase in longevity, the lower birth rate, and the changing roles of women, in combination, that have produced a whole range of problems, of which the crisis in long-term care is but one.

So that would be a stab at how we would present what we're talking about.  Then, I think because we're all — I think a test of whether there's anything here is whether we can get Dan to move at all.  So I'm going to make one more stab at it.

Dan, one way to think about it would be, so what happens if we — if the country just muddles through, hoping that we will be able to take care of these problems as they arise through immigration or through various kinds of government programs? 

I think very predictably two things will happen, and with all the caveats about comparisons to Europe.  Nevertheless, Europe is already there, and their experience shows us two things.  One is that if you view this problem as a problem of competition for scarce resources, you are going to have conflict between the elderly and the people who would prefer to have government take care of the elderly on the one hand.  That's one group.

And the young poor families in our society on the other, and it would be desirable if there is some way to replace that conflict with the idea that we're all in this together and we have to solve that problem together.  So there's one set of predictable consequences if we just try to muddle through.

The other is more sinister, but you can see in Europe, as the economic crunch becomes heavier and heavier, and the conflict model prevails, that it's going to be tough times for the weakest and the most vulnerable.  And so Dr. Carson raised these really hard, serious, important questions.  We don't want to get careless about answering those questions.  We want to give them the serious attention they deserve.

So I would say the most striking part of the white paper was calling to our attention something we don't like to think about, that 40 percent of us are facing long periods of disability.  This is something new.  A hundred years ago pneumonia carried people off.  This is something new.  We don't have experience to tell us how to deal with it. 

And at the same time we're dealing with that, we have fewer childful — is that a word?  Child-producing families in our society than ever before.  And immigrants aren't going to make up for it.  They'll delay it.  It won't be — the crisis will not descend on us as quickly as it has on Europe, but it will come.

DR. FOSTER:  Well, let me just comment about my immovability, and I'm listening carefully.  But I was once accused by some medical students, because I had written an editorial in The New England Journal of Medicine where I said that the level of the blood glucose did not relate to the complications of diabetes, you know, with blindness, and so forth and so on.

And then, subsequently I had changed my mind.  They said, "Well, Dr. Foster, why did you change your mind?"  And this is a statement that I always say.  When the evidence changes, I change.  Okay?  So, and when the evidence doesn't change, then I don't change, whether that's medical or otherwise.

And a big study was done that showed that the editorial that I had written was at the time correct, but subsequently in a massive study of the effect of glucose showed that we were wrong, because we didn't have enough data to do it.  So I'm listening carefully to see if there's any evidence that would persuade me that I am wrong in my position.

Can we muddle through?  I mean, I'm perfectly — I was on the Dallas School Board.  I know perfectly what Charles was talking about and the detrimental effects of some public policies that we take.  The health care in Britain, and so forth, I mean, has in many ways — or Canada has in many ways been flawed.  I'm talking about the single payer things.  They're not good systems in one sense.

But they're better systems than having 40 million people who can't get any care at all, I think, and that's — so I'm perfectly willing also to look at the things.  But I'm just — I only want to say that when the — I will — I am listening very carefully, Mary Ann, even if I don't show it.  Okay?

CHAIRMAN KASS: To help provide more evidence, could we return to the way properly chastened by Dan's admonition, to the original question, which was:  to what extent do we have an adequate terminology and an adequate diagnosis of this problem?  We've got just about a few more minutes in this session.

But, I mean, what do we think about the way in which this problem has been presented by Mary Ann, with Peter's cautious — is that a hand?

DR. LAWLER:  Robby George, a little while ago, used the phrase "unchosen obligation."  But under our law, I think there is no such thing as an unchosen obligation right now.  So I have every confidence in the world that Gil's children will care for him if he falls in the 40 percent, if he's lucky enough to fall in the 40 percent and nothing else gets him first.

On the other hand, they don't have to.  They can — anything might happen under our law, because our law is becoming progressively more choice-constituted, progressively more individualistic.  But our whole system depends upon people taking unchosen obligation seriously anyway.  People think of themselves some of the time not as individuals.  People think of themselves some of the time as children.

And even a standpoint some of the time citizens have — if there's a vacuum, then government ought to step in.   But it's not self-evident to me it would be the best thing if government stepped in.  If government steps in, it means there sort of is a cultural problem, because individuals are not — people — Americans aren't doing what they have always done in the past, so to speak.

And it's also unreasonable to believe that any economic solution could solve the problem, or, in fact, you could only make the problem worse — our inability to talk well to make sense out of the tough phrase "unchosen obligation."  So if we were to go around the room and talk about what unchosen obligation means to me, we would have a number of different and conflicting answers.

Nonetheless, Professor Binstock said last time — I actually looked into this — a billion and one studies show that the whole future of our health care system depends upon Americans taking the idea of unchosen obligation seriously.  And so maybe we can take it seriously.

DR. FOSTER:  Could I just make one, and then I'm through for the evening, for the day.  The other — we've talked about these economic issues, and everybody wants to talk about the cultural issues.  But one of the other things that's going on in our country right now, it's not only the already uninsured, is that every company that is struggling with economic survival is cutting pensions and retirement.  And so what we're seeing is our small businesses don't give health insurance or retirement.

So you've got a drastic — unless something amazing happens to our economy, the middle class people are not going to have any money — you know, it's $30- or $40,000 a year right now if you have to be in an institution, or you have somebody around the clock in a home.  Many places — $50,000.  Not many people in their retirement even now have $50,000. 

But if you have your retirement cut — I mean, it's not just the airlines.  It's in every — every business is cutting the benefits to their employees, and that's another risk that is under the economic rubric that makes me think that that is such a central part of the problem.

CHAIRMAN KASS: Let me ask you this, Dan.  Just taking a possible — thinking about down the road to possible policy recommendations that might be offered here, do you think it makes a difference, speaking now both as a clinician and as a man who has been around a number of decades, do you think it matters whether we think about building large nursing homes for people with dementia, or whether we choose instead to reimburse home nursing, providing care in the homes?

In other words, is the way in which one sort of thinks about the — and, obviously, there can be different solutions for different people at different stages.  But if you really see this as, let's say, society's attempt and an act of solidarity to stand with people who do not have their resources, it matters a lot which of the possible — which of the possible alternatives we offer, and which ones we would recommend depends partly on questions of feasibility but also partly in terms of the goals that one would like to be supporting.

Do you think it's out of the question that in days of fractured families, fewer children, many people are going to get to old age and have no children whatsoever to expect to have, you know, these — what was the — unchosen obligation.  Do you, nevertheless, think that we should make every effort to support families in their ability to care for their own?  Or do we want to say the community will care for it; it ceases to be any particular group of people's obligations locally?

DR. FOSTER:  I said I wasn't going to say anything more.  I would much prefer a system, an economic system from the government that would place health care workers in the home and for the family as opposed to building more buildings.  Now, if you're comatose and, you know, you're going to have to be taken care of 24 hours a day, sucked out and turned to keep from decubituses, you just can't do that, even with — you know, with — because we're not even talking about LPNs. 

I mean, we're talking about people who have been maids before, you know, who come in and oftentimes form, you know, very close relationships with families.  I think that's a very important way that would help conserve some of the other things that people have.  So if you ask me, "Do I want to build more nursing homes, or would I prefer to have people being able to come home?" the latter overwhelmingly, but that's — I don't know which will be economically more expensive or cheaper.

CHAIRMAN KASS: Okay.  Diana?

DR. SCHAUB:  But both what Charles mentioned, speaking about the unintended cultural consequences of economy policies, and what you're talking about now would require talking very much in terms of policy prescriptions and trying to make predictions about the results of specific policies.

CHAIRMAN KASS: Indeed.

DR. SCHAUB:  And it seems to me that would be — well, I don't know, somewhat different than the broadening of the framework of discussion approach.

CHAIRMAN KASS: Yes.  No, I was using that as an example to try to indicate that when one came down to the question of policy, and one would, of course, try to think about the unintended consequences of doing A rather than B, I was teasing out from Dan a certain intuition that he has both as a physician and as a human being about what the desirable nexus of care would be, other things being equal and without exaggeration. 

And that depends — what that means to me is that he has, whether articulated or not, a certain tacit understanding of both what the dilemmas are and what the more desirable alternatives are.  And I think it's very important that those tacit understandings be made conscious and explicit, that it — that Dan, in other words, is interested, as I think most people in this room would be, and not only for themselves but as much as possible for as many of our fellow citizens, that they should not simply be cared for in the sense of tended to, but in places where people actually care, not because they still remain connected, not withstanding their diminished status.

Now, it may be economically infeasible to do that, but before one simply adopts the economic solution — if I could just repeat myself — it would be nice to have that firmly in mind, that one doesn't want to pull the rug out from under that in unintended ways.

Charles?

DR. KRAUTHAMMER:  Mary Ann asked how we might sort of — what we might call this issue.  I think what we're looking at is we might call it the economic and cultural consequences of the adult-centered society, and I like her formulation.  It's not just care for outsiders.  It's what happens when the median age of a society is rising?  It's attention, the center of gravity, all the political weight is in people of increasingly rising age.  What happens?

It's an extremely interesting question.  On the economic issues, I think we could be more policy-oriented because obviously a lot of work has been done.  On the cultural, I think we would have to be more speculative and sort of cautionary, saying, "If you do X, it might have a cultural effect."

But I just want to throw in one datum, which is I was just reading a paper by Nick Eberstadt on infertility in the Western world, and it is astonishing.  He points out what we really often overlook.  The United States is the only advanced industrial country anywhere that is maintaining — has got a replacement rate for its population, and it isn't only immigration, although it puts us way over the top. 

He points out that if you take it away, we're about — we're between 2.0 and 2.1, which is essentially replacement, whereas the average in Europe is 1.4, which is catastrophic.  It means that you lose a third of the population every generation. 

So the interesting effect of that is that we have a laboratory.  We in America have a real cushion.  We do have a crisis approaching, but it is approaching slowly.  It's slouching towards us.  It's not crashing in on us.  It's crashing in on Europe, and we have the advantage of looking at what is happening in Europe, where it's happening at an unbelievably rapid rate — median age is rising by — you know, dramatically, and really unprecedentedly.

Here it's going to happen a lot slower, because we are replacing our population, and we are incredibly agile and experienced at absorbing immigrants.  So we have a cushion.  Even though it's going to be a problem, it's still — it's not a year or two away.  It's a decade or two or three away.

And using the laboratory of Europe and East Asia, interestingly, which is also in demographic collapse, we can learn a lot about the economic effects and the cultural effects, which are far more subtle.

So I'd suggest as part of this inquiry we could use or get experts like Nick and others who have looked at this and can talk about what's happening in Europe today, East Asia today, and that would inform us.  It would not be all speculation.  It would tell us what really happens when the median age jumped from 20 to 40 within a generation.

CHAIRMAN KASS: Last comment by Robby, and we'll take a break.

PROF. GEORGE:  Well, I forget who said it, but it's true that disagreement is a very hard thing to reach.  The trouble is in discussions and debates of this nature, people very frequently talk past each other, and they think they are disagreeing, but sometimes they are in what my friend Hadley Orcus calls "heated agreement."

So I'm not sure whether we've managed to reach disagreement yet, or to some extent we've talked past each other.  So let me take a little stock.  Please correct me, Dan and others, if I'm wrong in this stock taking.  There is an enormous demographic problem having to do with aging, and the aging of the population, life extension, birth, dearth, and so forth.  And this problem has enormous economic consequences and bears very heavily on people at the lower end of the socioeconomic spectrum.

I think everybody is agreed about that.  I think also everybody agrees that it's a societal imperative, it's an ethical imperative, that we do our best to come up with a system, whether that system tends to be more market-oriented or more social democratic, but some sort of solution to the problem, to the extent that problems like this can be solved or at least managed, that comes to the aid, especially of those who are most in need, which is not people like ourselves around the table but a lot of other people in the country and in the world.

Okay.  Agreed.  Now, some of us have been also pressing the point that in thinking about the problem we ought to be aware that thinking about it in cost-benefit terms, or purely economic terms, will mean neglecting ethical issues which arise by virtue of the fact that any proposed policy solution or managing — management of the problem will have effects, some of which are not obvious, some of which are probably utterly unpredictable, but not — probably many of which are at least not obvious, and they're worth thinking about.

And that if we think about them, we have to think about them in light of ethical concerns we have about what kind of culture is a good culture for human beings to live in. 

I don't think, Dan — correct me if I'm wrong.  I don't think that you are quarreling with that, just as we're not quarreling with the proposition that this is an economic problem that bears very heavily on the poor and has to be thought about in those terms.

But if that's right, then where is the disagreement?  We're not economists.  We can't solve the economic problem.  But we know that we have to think about the ethical issues in light of different possible economic solutions ranging from the more social democratic to the more market-oriented.

Are we not putting enough emphasis on the economic side?  Are we failing to see that the economic solution really is more obvious than I think it is, or that some of us at least think it is?  And that if we focused on it properly, we would see that we can eliminate some of the possibilities on that spectrum from the social democratic to the more market-oriented, and that a truly — a sound concern about ethics would be focused on narrowing those options to the ones that seem to you to be the right ones?  Or where are we?  Do we disagree?

CHAIRMAN KASS: Could I speak on his behalf, since we've talked about this at length?  If you'll allow me.  And if I don't do you justice —

DR. FOSTER:   You'd do it anyway, so I have to allow you.

CHAIRMAN KASS: No, I wouldn't.  I wouldn't do it anyway.  I wouldn't do it.

He was very careful at the beginning.  It was not, is this an enormous problem?  The question is:  is this an enormous problem that this Council can say something useful about as opposed to simply wring our hands and saying, "This is an enormous problem, and it would be nice if we could do something about it."

He's a practically-minded fellow, at least as — in many respects, but as a member of this body, it may be that he might want something in which we are able to say yeah or nay, but at the very least to say something about which people won't say, "That's nice.  They met.  They talked.  They worried.  They wrote.  So what?" 

And I think it's absolutely salutary for the President's Council on Metaphysics to take such admonitions and challenges to heart.  It would not be enough for us to simply have an interesting conversation.  If we can diagnose the problem in such a way that helps people actually think concretely about how to make it better, I'm fairly confident if Dan saw that we were able to do that he wouldn't mind.  But he hadn't yet — at least at the beginning of this session, hadn't yet seen that we have done that or are sufficiently far enough on the way to make him satisfied with that.

As my client, did your attorney do a good enough job?

DR. FOSTER:  Yes.  I thought Robby's summary was very good.  What I've tried to say, and it may — and you pointed out — is, I just want to have — I'm not against ethics or against morals or against wishing the culture of the nation was better and trying to work — I just want to do it, as you say, in a way which might have some impact rather than just writing a report that somebody might read and say that — okay, that they sat around and did it, that there ought to be something that could be defined by questions. 

I mean, one of the things that Ben and you talked about, and we're going to talk about tomorrow, is what are the limits, for example, in health care in terms of the economy.  So, yes, I'm — that's a — you did a very good job for me.

PROF. GEORGE:  Can I ask either counsel or the client one question?  Just to be perfectly clear.  Is Dan — Dan, are you asking for us to make specific policy recommendations?  Or would it satisfy the concerns, as Leon has articulated them, that we have raised concerns — if in the end this is what we do — raise concerns about ethically significant issues having to do with the unintended consequences of proposed solutions to the economic dimensions of the problem.

If it were the latter, would that be a disappointment to you?

DR. FOSTER:  No.  I mean, our previous experience in terms of enhancement did not result in any sort of policy decisions.  Our decision as we came along, in terms of stem cell, resulted in policy recommendations.  So it might be yes or it might be no.  I just don't want us to muddle around. 

I mean, I think we ought to say what we're going to do to see if we could be helpful.  That's all I care about.  If it should, and our time is short — maybe very short, depending on, you know, whatever happens with the elections.  Either way, you know, but — but we don't have time, as Charles said, to do all of the economics. 

I mean, the best people in the world are thinking about this, you know, and so we — but we might come to a conclusion about an approach that Leon posed to me about enhancing care for the elderly in homes when the family does not exist anymore that would help — to help personalize it and maybe have tenderness and love there as well.

So the answer is, no, it would not mean that I was out of it if we didn't have a policy decision on that, no.

CHAIRMAN KASS: Let's take 15 minutes.  We'll return to allow Gil Meilaender to be a burden to all his friends.

(Laughter.)

(Whereupon, the proceedings in the foregoing matter went off the record at 3:37 p.m. and went back on the record at 4:00 p.m.)

SESSION 4: AGING AND CARE-GIVING: REFLECTIONS ON THE BURDEN OF CARE

CHAIRMAN KASS: Well, I probably can fumble away a couple of minutes while the stragglers return.  I'll be very brief, actually.

In this fourth session, the title of which is Aging and Care-Giving:  Reflections on the Burden of Care, we move from the large, amorphous, societal, cultural and political questions, of providing long-term care to narrower ethical and familial issues of the relation between the old and the young, between those in need of care and those who are called upon to give it.

I should say at the start that this question is less about a vexed, ethical conundrum with an "Are you for it or against it, yea or nay?" conclusion, as it is about the proper ethical attitude or disposition that we ought to have in this area, and not, as is the usual case, what is the disposition of the strong toward the weak and needy, but rather what is the proper disposition of the old, the weak and the needy or those who contemplate becoming old, weak and needy toward their young, strong and abler loved ones, and, in particular, their descendants.

And the general question is, what is the right or noble or decent way to think about what we, the old, and soon to be enfeebled, owe to our own loved ones and potential care-givers.  Should we be interested primarily in easing their burdens or enabling them to shoulder them?  That would be a shorthand way of putting the question that Gil Meilaender's provocative paper has produced.

The little paper was published in 1991, if I'm not mistaken.  I read it at the time and I thought, "What a guy, to take—to say such a thing in public, 'I want to burden my loved ones.'  How could anybody say anything like that?" And I filed it away.  And then when we were sort of thinking about this question and the question of the ethical obligations of the old to the young, I remembered this paper.  It turned out to be very short.  I remembered it as being long and full and so I pressed Gil to expand it and he wrote a dialogue with some strawman interlocutor which made the case on his side much too easy.

And so I had another argument with him on the phone and I said, "Look, Gil, let's give the other side the benefit of the doubt and so — truth in advertising — he constructed this dialogue using the friendly interlocutor, assigning to the friendly interlocutor who resembles the Chairman more than a little, the best arguments he thought the Chairman could make, and he then saw fit to answer them.

I will reserve the right to speak in my own name, without counsel, in the discussion, but thanks to Gil for extending those remarks and stimulating us to think about what is I think a very serious and important topic, at least for us, as members of families and therefore, by implication, for how we want to think about this thing in the large.

I've asked several people to offer beginning reflections and their responses to the questions raised by Gil's paper and I'd like to start with Janet Rowley.

DR. ROWLEY: At the outset I should emphasize that I formulate my response not as a philosopher and ethicist or a political scientist and I could just hear Gil reading this brief essay written in 1991.  It's full of surprises of unusual, I might even say, perverse points of view.  Consider the title for starters.  I want to burden my loved ones. 

In his paper, Gil tries to make a case that to be mature, moral, human beings we must be willing to accept unwanted and unexpected interruptions to our plans and we've already alluded to this in the earlier discussion.  And then he goes on to say perhaps the best way to develop such human beings is to burden loved ones in our dying.  Later in the expansion that Leon has mentioned, Gil states that he chose a catchy title to get attention and that, in fact, he does not want to be a burden to his family.  And then this is further expanded under Tab 12 between Gil and the friendly interlocutor that clarifies and I have now just learned, updates Gil's thoughts on a number of issues, particularly the responsibility of one's children.

Gil makes a valid point which has also been raised in our earlier discussions this afternoon.  The families are connected and that of necessity means that members have claims on one another, although often our society seems to deny these claims.  In the context of family, one should expect to accept whatever comes, unbidden and inopportune as it may be.  A quote from Gil, "we wither before we die and therefore somebody must take care of us."  And Gil suggests that if you don't want to be dependent, then you just drop off the edge.  The question then is, aren't there limits on the burdens we can lay on others?  And then the problem becomes to define those limits.  And he says we're only obligated to do what we can do.

It also depends on the nature of the burden.  Decisions about management of end-of-life care are one type of burden.  Actual on-site physical care for an individual is a very different burden.  So too are the family relationships: husbands and wives make a contract until death do us part.  Children make no such contract.  Here, the dialogue brings in the community and the fact that the community has limited resources and must make choices and then the dialogue ends.

So what are my concerns and how do I respond?  I would echo everything said about the potentially ennobling impact of taking care of the dying loved ones, if the individuals involved are psychologically and financially able.  I've watched many dear friends die and I thought that I hoped I will die with the same dignity that they did and with the loving care and support that they received from their families.

For myself, I've struggled with this same question and concerns, but from a different perspective.  When I wither, I believe I have a responsibility to figure out how not to be a burden to my husband and my children.  Gil and others may consider this selfish, however, that's the way I was brought up.  My mother lived in fear that she would be a burden to me and she did everything during her life to prevent that.  In fact, she died suddenly at age 82, being active until the very end. 

My husband had a similar experience.  His father vowed that he would not be dependent on his children and he was not.  So that's how we brought up our children.  They have their own responsibilities and families and care for their families is helping to make them, I hope, at least, more mature and more moral human beings.

I want to expand this and this will, in fact, be somewhat repetitious of our morning or our earlier conversation this afternoon.  I think these opposing views play out in our society.  Some think it is their right to be taken care of.  Others, that it is very important to be self-sufficient.  Clearly, unexpected catastrophes occur and the most prudent plans may be for naught.  Equally, many poor people cannot plan for a secure old age. 

Now I've spoken sometimes and people may think intemperately, about the moral and ethical responsibility of members of our aging society to the young.  Our society is constantly making political choices.  We choose to spend many billions of dollars on Medicare because it's good politics and the AARP and the individuals that it represents demand it.  I appreciate the fact that Medicare will provide various resources for me, if I need them and this will reduce the burden on my family, but I cannot avoid feeling very guilty that this help for me is borne by young children for whom no one speaks.

So just as the community issues were not settled by Gil and the interlocutor, I can't develop a politically acceptable plan to balance the needs of powerless children with the demands of powerful seniors. 

That said, to be true to our charge as a bioethical council, shouldn't we focus on devising a morally robust resolution of care for all members of our society at both ends of life, the beginning as well as the end?  We're currently considering one aspect of the complex interlocking problem, namely society's responsibility to older citizens, especially disabled older citizens, without simultaneously considering the potential impact of these discussions on the resources available to the young.  Our discussions have not been framed in the context of choices.  For me, that is a potentially fatal flaw in our current proceedings.

CHAIRMAN KASS: Thank you very much.  A lapse of memory keeps me from—oh, it was Charles, I think.  Okay.

All right, then let me simply declare the floor open for general comments.

Michael Sandel.

PROF. SANDEL:  I have a question for Gil, but I'd like first to say how much I admire this essay, above all, for its ornery, grouchy, contrarian charm.  And there was a subtext, a figure, a theme that I thought was most revealing and amusing which was the crotchety view of athletic activity as when Gil describes himself sweating in the hot sun teaching his four children to catch and hit a ball.  No dewy-eyed romanticism here of fathers playing catch with their kids or to swing a tennis racket or to shoot at free throw.

This is hard, arduous work and I pictured Gil, as I read this last night, running alongside the bicycle, ready to catch the child who might fall while learning to ride, sweating, puffing, panting and resenting it all the way.  I loved it.  So that's to express my appreciation for this, well, picturesque essay.

My question is this, granted that there is a virtue in conveying to children the moral teaching that you can emphasize here about accepting unchosen burdens and responsibilities and accepting interruptions in plans, granted that basic moral concern, do you think that there is an asymmetry in the willingness of children to bear burdens for their aged parents, an asymmetry between that willingness and the willingness of parents to bear burdens for their children, do you think that there is and if so, do you think that that asymmetry is just contingent or the product of a kind of selfishness on the part of children, failure of moral education or do you think that asymmetry, that there is something to that asymmetry?

PROF. MEILAENDER:  I take it you said, "Do I think there is," but I take it you mean, "Should be actually, not just is," right?

PROF. SANDEL:  Both.  Do you think it runs insofar as there is an asymmetry, do you think it runs deep or do you think it's something we should ideally try to eradicate and rise above?

PROF. MEILAENDER:  No.  In the discussion with the friendly interlocutor, who is very friendly, and who pressed a somewhat similar question, I think I acknowledge at some point that there is a sense in which part of the understanding of being a father, a mother, is indeed that you are trying to enable the child to get started in life and that's a little different.  I mean it's not symmetrical with anything in the responsibility of the child.

On the other hand—so I want to say yes, in part to what you said, otherwise we'd just all be sort of people and we wouldn't be people at different stages of life, connected in different kinds of ways.  So I do think there is an asymmetry.  But having granted that, I guess I'd want to say that and you know I've said it several times in different ways and I'm only going to be repeating myself, that part of launching one's children well in life would be precisely seeking to inculcate these lessons that you mentioned.  And I don't know too many better ways to do it, too many ways that are more naturally connected with the course of human life than to make something like the kind of point that I was trying to make here.  So that it's asymmetrical, but children just by virtue of being children of particular parents do, I think, also have some responsibilities.  They're not formative responsibilities in the same way, and hence it's not symmetrical, but there are still tasks that fall to them and we'd be deficient if we failed on them.  And we all do fail on them to some degree and we're all deficient to some degree, but we should recognize that.

Am I getting to what you asked?

PROF. SANDEL:  So would you say that the impulse of some parents, and Janet mentioned this impulse, to spare their children this burden, would you say that that isn't a noble impulse on reflection?

PROF. MEILAENDER:  Oh no, it's noble.  There are lots of kinds of nobility.  And it's not even entirely bad.  I think that one would have to see how it works itself out in every particular parent/child relation to know what one wanted to say about it.  I think it would become worrisome to me only insofar as we begin to think about it in a way that started to communicate the sense that the best thing was really to be self-sufficient.  I mean Janet used that word.  Now that's a word, see, I think if I communicate to my children the best thing would be to be self-sufficient, in my lingo, I'd be teaching them to live a lie.  None of us is self-sufficient.  I wouldn't want to communicate that.

So if it works itself out in such a way that that's what I teach them, I've made a drastic mistake.  That doesn't mean that in lots of ways, I mean we may not also try to relieve our children of various burdens.  You don't just pile them on as much as you can for the sake of their character, but certain ones that cut very deep into human life may be we're better not relieved of.

PROF. SANDEL:  Would you go so far as to say as there are, we've been told 40 percent of people are living in kind of a disabled condition, but in the case of those parents who are fortunate enough not to be in circumstances of need and posing a burden, given the like, would you say that they were depriving—would you go so far as to say they were depriving their children of something important?

PROF. MEILAENDER:  I might in some cases, yes, and maybe their grandchildren, too.  Their parents could give an example of precisely what it means to be a human being who recognizes those unchosen obligations.

Again, I don't want to make it too strong because in the nature of the case, I don't think there's kind of a cook book recipe here and I don't think there's sort of a one-size-fit- all principle, but I'd be willing to contemplate the possibility that it was a deprivation, yes.

CHAIRMAN KASS: Can I come in because my concerns are, as you know, similar to Michael's and similar to Janet's.  And I think I accept your understanding of the meaning of our connectedness, of these unchosen ways and Janet put it, I think, beautifully, the spousal relation is chosen in a way the child-to-parent relationship is not, in the best case, even though the child's existence is spoken for affirmatively by the parents who make way to have such a child.  The child is just there. It's certainly true that the Western Biblical tradition makes it a commandment to honor your father and your mother, (presumably because it needs commanding), but somehow if we're in good families, many people would feel the pull of being helpful and being caring toward their parents.

But thinking about it as an aging parent and grandparent, I'm more moved by other considerations, at least additional considerations and they don't have something to do with not wanting to interrupt the lives of my children as much as it is to play out the meaning of a couple of—one is a proverb and one is a small parable.

Yiddish proverb, when a father helps his son, both laugh.  When the son helps the father, both cry.  Now tears are part of life and when it's time for weeping, it's somehow appropriate.  But it's perfectly appropriate for my mother to change my diapers as a young child.  It is somehow—it might be obligatory that I change hers should she become incontinent, but it's not because—or that my children should have to change mine.  It's not because I'm afraid of interrupting their lives, I'm afraid of somehow inverting and jeopardizing the kind of relation that I've had with them throughout my life which is a relation of parent rather than of second child or someone in second childhood.  So it's not just the question of not wanting to burden them, but wanting somehow to preserve these relations and allow this thing to go forward.

The parable and my wife Amy and I have a disagreement about the original version of this.  It's a parable told by the Rabbi of her mother's congregation some 15, 20 years ago.  It's a story about a bird of unspecified gender.  Amy thinks that it was a mother bird.  I think it was a father bird, who was carrying fledglings just learning to fly up to a big river.  And the adult bird gets the first little fledgling up on the shoulder, takes it across the middle of the stream and says "little bird, little bird, when I'm too old and feeble to fly, will you do the same for me?"  And the little bird said, "of course, father" in my case or mother in Amy's case, "I'll do the same for you" at which point the bird with a twist of the wing drops the little fledgling in the river and drowns it.  And does the same with the second.  And he gets the third little bird up there and he says "little bird, little bird, when I'm too feeble and old to fly, would you do the same for me?"  And the little bird thinks for a minute and says "No, father, but I would do the same for my own children" at which point this little bird was taken across to the other side.

There's something right about that story.  There's something, I think, right about the attitude of that story.  Not that we should be callous, but that we should somehow want primarily that the work go forward and not be deflected unduly by the care of ourselves in our enfeebled condition.

I would be disappointed if my children didn't feel the impulse.  That's to speak about their side.  I can count on them wanting to do it, but I think it would—and there are things to be learned about the sadness of human life and what we're summoned to do in our unchosen obligations.  But I don't—there's nothing in me that wishes to summon them to do that work.

PROF. MEILAENDER:  Do I get to respond?

CHAIRMAN KASS: Sure.

PROF. MEILAENDER:  Just a couple of things.  You're right, that spouses have chosen each other in the way children have not quite chosen to be children in this family, that's exactly the sort of experience that the existentialists used to like to talk about is thrownness and finding oneself in the universe.  All the more reason why it's a more fundamental place where one's character is shaped, where you learn whether you're really able to come to terms with the contention.  So the description is right, but what we conclude from that, I think is still up for grabs.

But then just a couple of brief comments that get to the gist of your saying and your parable.  You want the work to go forward and I want to know what the work is, exactly, you see.  Is the work just getting on with my projects?  No.  I would like to get on with my projects.  Actually, I'd like quite a bit to get on with my projects.  All the more reason why I need to learn that the work has to do with the relation between the generations. 

And I guess—and here we come, I believe, to what really does lie at the root of the difference.  This inversion that seems to you unnatural, finally, doesn't seem unnatural to me.  If growing old and aging and becoming feeble and unable to care for myself is part of the trajectory of human life, then of course, although I will always be a father to my children, that will not mean the same thing any longer.  It will have to be inverted in some ways.  It's very hard.  I'm not sure for whom it's harder, probably for the parents, although not always.  But it doesn't seem contrary to nature to me.  It seems precisely part of the natural trajectory of human life, that those of us who live long enough should get there and ought to not be bothered by that.

DR. ROWLEY: Actually, in the interest of not going on and on in my commentary, I cut out just a sentence that said that part of my wishing to try to figure out how to get out of my family's way, if I'm incapacitated and I still am able to do something about it, is the notion that I want them to think of me as the kind of person I was when I was competent and able and that to the extent that their memories of me are then clouded or—that isn't the right term and I can't think of one right now, but are changed because of me in an enfeebled state, that's something that I personally and maybe for vanity really would like to avoid and it's of great concern to me as an individual that there are some aspects of our society make some of those kinds of choices for some of us more and more difficult to reach and I think that we should be more amenable to allowing older individuals to choose, have more say over how they end their lives than we're willing to do right now.

CHAIRMAN KASS: Peter and then Paul.

DR. LAWLER:  I agree with Janet and Leon.  I only have one kid.  That I would not choose to burden my daughter in this way, maybe for reasons of vanity, maybe for reasons of preserving the proper relationship between father and daughter.  But we've already said so many times today, 40 percent or so of us won't have any choice but to do this, so I can willingly take refuge in the thought that it will be in many ways good for her if I do it.

Now Dan might object.  This is very touching of us to be saying these things, but what are the public policy implications of all of this, to which I can only respond at first we should all be like Gil and maybe all Americans should be like Gil for then we would have no problems.  That is, we should all have lots of kids to minimize chance there and to spread out the burden, I think at least four.  We should all get Ph.D.s in something like religious ethics so that we can properly instruct our children in the joys of unchosen obligations  or whatever the phrase is we're using.  And then we could just go home for the rest of the day because there would be no public policy problem.  The children would step in.  The only role of the government would be to assist the children in a minimal way of accepting the burden they have no problem accepting. 

It would be better if they're like Gil and like the very rich Dan, a combination to make sure everything is okay.  But the problem we're facing is our public policy situation is and this is sad to say, very few of us are like Gil.  That is, very few of us have Ph.D.'s in religious ethics.  Very few of us have lots of kids.  Very few of us have lots of money.  And so the solution given here which I think is a beautiful moral solution to the problem 40 percent of us are going to face is not a solution applicable to society generally.  And that's because most of us don't think like Gil.  We think more like individuals who tend to maximize choice.

And I do agree with Leon, there reallyis an asymmetry here.  Raising children is nothing but a joy and rarely a burden because the children are full of promise, always progressing, on the way to something.  Watching your parent move away from something and something which is natural, yet unnatural.  We can say it's natural to die of Alzheimer's, one point of view, but from another point of view, for a long history of human nature, hardly anyone ever did.  And so this is something—even if it's natural, it's something new that parents fade away in this way.  And so the burden, I would say that children who do this will learn all sorts of things about human beings, are ennobled and deepened in many ways.  But it's much tougher than raising children.  And for that reason, they're ennobled and it's for that reason they learn, but we shouldn't minimize this or even expect children nowadays for all the reasons we've talked about to do this routinely.

So the question remains, what exactly is a public policy implication of Gil's wonderful writing here?

PROF. MEILAENDER:  Leon, let's get on the record that more Ph.D.s in religious ethics is not the answer.  Okay?

(Laughter.)

CHAIRMAN KASS: Do you think it's a matter of indifference with whom they study?

PROF. MEILAENDER:  No, I think it has very little to do with that, actually.  I just think that what you learn at your mother's knee is probably much more important than a Ph.D. in religious ethics.

CHAIRMAN KASS: Let's see, I have Paul, Alfonso and Rebecca.

DR. McHUGH:  I really don't know how to enter this conversation because I agree with almost all the sentiments that were expressed.  And I thought perhaps the best place would be to come in with a slight disagreement with you, Leon, when you said that "Honor your father and mother" might be there because it was perhaps not something we did naturally. 

I don't like this description of Moses as a kind of public health figure or anything of that sort.  I like to see him as someone who is deciding for us what might be first steps towards the rest of the things in the second table, the reason that only a father and mother is where he positioned it, rather than further down, do not steal, adultery and things of that sort, was because he felt that that was perhaps the place where character might be formed.

Now I don't believe that he meant by "Honor your father and mother" that necessarily had to involve for you or for everyone else that you became expert in adult diapers.  But I do think he did mean for us to understand that it's through this understanding of growing infirmity that we saw life as it was and prepared ourselves, formed our character to deal with the other demands, temptations and other things which would come up in this life.

For all that I agree with and many of the different expressions of particular situations that would be extra burdens and I wouldn't want to put on my children.  At the same time, I think that my children should be thinking what it means best to not just honor what I felt as my role such as I want to always be in control, but being in a place where they decided how honoring me or my wife, let's say better, would help ultimately for them and the children that come after them.

I've said this before at these meetings on things of this sort that our times have just changed so radically.  When I grew up, everybody had old folk in the home.  Everybody had to do certain kinds of nursing tasks.  Certainly in my home my mother took care of her mother and her aunt until they died and did a variety of things that sometimes I very much resented, taking time away from me for it.  But on the other hand, I felt that this was not only what my mother was before, but that in the process she became even more gifted as a person in this life because she did do that and that I learned from the experience.

So I come in at that level.  Why is that commandment out there in the position it's in and why should we be seeing it as a kind of thing that is imposed upon us?  For a psychiatrist who is interested in helping people develop their character, this is some place where I like people to begin.

CHAIRMAN KASS: Let me hold back and I'll respond later on.  There are people waiting in the queue.  Alfonso.

DR. GOMEZ-LOBO:  I'm not sure whether Gil needs an attorney at this point, but I'd like to side with him, whether he accepts me on his side or not, I don't know.

First, I think, of course, there is playful ambiguity in the expression "burden one's children."  Of course, there's a sense in which we do not want to burden them in a general prudential sense, you know, we want to have our health insurance, we want to be clean on all of that.  I think it goes much deeper.  It has to do with this radical contingency of life which has been my experience in life.  In other words, no matter how much I prepare things so as not to be a burden for my children, I'm open to the possibility that it might well happen.  Who knows?  I may end up being taken care of by one of them in spite of the fact that I've all kinds of arrangements not to be.

And that's a point where I don't like your second parable and it's this.  I think that you know I'm deeply committed to my mother.  My father passed away already.  But I would never ask my children, "Are you going to take care of me in my old age?"  I think that part of the love one expresses to them is to be totally selfless in that regard, perhaps expected, but never sort of asking for it.  That would be the only way I would view it.

Now considering that, I am in symphony with what Gil says.  It may well be that I will end up caring for my mother in ways which I will find natural, in spite of the fact that it may not correspond to the expectations, conventions, etcetera.

Now a final point about the image one leaves behind.  Again, I'm open to contingency.  I want my children to perhaps remember me as a young father, then as an aging father and then perhaps as a very feeble father.  I just want them to remember me as having a sense of humor, even at that stage.

CHAIRMAN KASS: Rebecca, please.

DR. DRESSER:  I come from the type of family, my mother and her mother, of an "I don't want to be a burden."  That was their attitude, and I think it has good impacts on children, that is, I think it goes along with fostering an attitude of "don't be a whiner, do what you can for yourself," that sort of attitude.  But I can see two negative effects.  One is, I think it's unrealistic because of the contingencies.  And I think it probably—it's not vanity, it's pride, it's hope.  It's hard to think about ourselves as becoming dependent, so this sense that well, I can set everything up so I won't be a burden to anyone, I think is often illusory.  And even if someone stays in physical health, they're still getting frail and so there is going to be a worry, a psychological burden and there's no way you can avoid that.

I think being in touch with the fact that one's children will be worried about you is probably a good thing.  It makes you more responsive to them.

And the second bad impact I think it can have is I think it makes it difficult to ask for help when it's needed.  And so there is an effort to try to manage something that could be easily managed by a family member or someone else and there's an effort to put that off and there's a lot of unnecessary burden on the individual there.

CHAIRMAN KASS: Mary Ann.

PROF. GLENDON:  I think there is a large overlap, actually, between Gil and Janet in the sense that listening to them it sounds as though both of them, and you too, Leon, are very concerned with the parent's role as a teacher, teaching children about how to live and ultimately teaching children how to die, so that when Gil says provocatively that he wants to be a burden to his children, as I read him, he's saying I want to teach my children about how to be a certain kind of person.   And when Janet says she most definitely doesn't want to burden her children, she's not saying that she hasn't tried to bring her children up to be the kind of people who would be only too ready to assume that burden, if need be.  So I do think there is a large intersection there.

And this conversation reminds me of the short story that is in our book, Being Human, where we see a family in one of those stories in the Liam O'Flaherty story, that is simultaneously taking care of a baby and a senile elderly person and that story is very admonitory because here's a family that takes for granted that this has to be done, but the baby and the elderly person have the same kind of needs.  They both wander off and they have to be confined.  They both have to be fed and cleaned and personal needs attended to.  The family does it, but they do it with such hope and joy in the case of the baby and it is a real chore in the case of the old man.  I think we just can't get over that. 

So one of the things that it seems to me everybody is concerned about, it's not vanity.  It's more again the sense of what you want to teach your children.  We would like to be able to teach our children something about dignified living and we'd like to somehow teach them something about how we meet the physical trials that come at the end of life.  And the dementias take that away from us.  This is really one of the ways in which so many of us are in a new ball game.

And then finally, I so much appreciated what Janet said about the importance of not losing sight here when we talk about an aging society, of what that means for our culture and the way we treat children and child raising families as adults become predominant and politically powerful.  So thank you.

DR. ROWLEY: I just—I have always been struck by a Japanese movie whose title I should remember and I don't.  It took place in I suppose the late 1800s or maybe earlier in a mountain village in Japan and the story was about the culture in this village which when individuals, if by chance, they reach the age of 70, the culture was for the oldest son to carry the septuagenarian up to the mountain to a cave area and leave them.  And they died.  And the efforts of a woman who was very physically fit and 70 trying to ruin her health so that she would die, but failing that, just forcing her son to take her up to the mountain. 

Now you can say that's so alien to anything that we think about and that it has no bearing on any of our conversation.  But I have to say I found that a very powerful and moving movie.  And it comes back to the question of what is the responsibility of the older individual to try to reduce their burden on not only the family, but in this case, on a society which is just living in a marginal way in a mountain village.

And I don't think we asked any older individual what is your responsibility to reduce your impact on society?  Again, an older individual who has Alzheimer's isn't in a position at least toward the end to be able to make those kind of decisions, but it seems to me that there is this continuing pressure of older individuals to say I want more and more.  And we're going to get to this tomorrow, I'm sure.  But shouldn't we think about the other alternative, and again, it goes back to using resources that I think would be much better spent on infants and young children.  But isn't there a responsibility of a responsible, older individual to think about using fewer resources rather than more?

CHAIRMAN KASS: Ben?

DR. CARSON:  One of the things that obviously has changed significantly is the fact that elderly people can be elderly for a very long time now.  It used to be that they would die, but now that can go on for 20, 30 plus years. 

Now I will say personally, like everybody else here, I certainly wouldn't want to be a burden on my children for any extended period of time.  I know my mother felt the same way and she's lived with us for 14 years now.  I don't consider it a burden at all.  I'm delighted to have her with us, to have had her influence on our children and I count it a privilege to be able to help take care of her because she did so much for me.

But recognizing that our society is growing older and that those family dynamics have changed and that there is a much more "me first" oriented society today than there used to be and I don't think that anything that we can say is going to change that.  I wonder if in terms of a policy issue, we should be looking at are there ways in which large groups of elderly people can be taken care of in a compassionate and in a way that's fun for them where they don't feel like they're a burden on their family.  It seems like we have the capacity to do that, as a society, if we use a little creativity.

CHAIRMAN KASS: If there are no hands, let me join in here with a brief comment to Ben and then go back to a couple of other things.

It seems to me to connect this conversation with the previous one.  We have a couple of paradoxes here.  On the one hand, especially in old age, the ties that bind us, other things being equal, increase in importance.  Career begins to fall away, it's the visits of those who mean something to us that sustain us and we look forward to seeing those who are our own.  And therefore, the belief that you could somehow substitute the care of strangers and the removal of the close ones is—it could be desired on the one hand because it doesn't burden those you love.  On the other hand, it substitutes—it substitutes paid-for companions and care-givers for the relations that one wants.

Now those of us who as Dan said, might have — might be well off enough, could have both.  One could get nursing care one needs either in the home or with enough opportunity to have visits and stay connected, but it seems to me that one of the paradoxes is one wants to spare one's loved ones the real burdens and I'm talking about the ones of caring for people with advanced Alzheimer's disease.  That's not like — just making a decision.  That's 24 hours a day and really exhausting full-time work — One wants to spare one's family of that and yet one doesn't want to, at least in the early stages of that disease, to having children simply cut out and institutionalize their fading parents.  So that's one problem.

And the other paradox seems to be in the way in which you look at this problem, from the two sides of the parent/child relation.  It seems to me perfectly possible to say one wants to teach one's children by example and exhortation, that they should be the kind of people that would feel it in their hearts to want to help out, to be there when needed, to be informed, to be present, to do what—you want them to be those kinds of people.  And yet, you're reluctant to be the object of that kind of attention yourself.

And I'm not sure how you slice this.  The grandchildren introduce a nice wrinkle into this because one of the ways you might be able to justify becoming the kind of person that your children would have to look after, although again, it depends upon how big this burden is, and whether it really robs your children of their ability to look after your grandchildren in the proper and full way, but it might be that the only way in which your grandchildren can learn the lesson that you have somehow managed to teach your children is to see your children actually giving care.  So that if you move this out from just the two generations and beyond, there might be some kind of example here in which this is the only way the young learn about the contingencies of life, and how parents step up to the plate when it comes their way and they can't avoid it.

But on the binary relation, it seems to be one might want to embrace this view: I want my children to know how to act when contingencies strikes me down, strikes someone down, but I sure don't want that it should be spent on me.  And I don't know how you cut that one.  This is a way in which one could perhaps agree with Janet and me and agree with Gil and Alfonso, simultaneously.

PROF. MEILAENDER:  But of course, I don't actually agree with your second point.

CHAIRMAN KASS: I'm sorry?

PROF. MEILAENDER:  Except of course, I don't agree with your second point.  It doesn't seem to me a bad thing that I should be the object of it.

CHAIRMAN KASS: Willy nilly, we are going to be, so it's partly moot.  But I don't see how—

PROF. MEILAENDER:  The first point is the point about what I would like the character of my children to become.  The second has to do with what I think my own character should be.  And you see, I think that what you're saying is I would like my children to learn how to really care for people who are frail and dependent and possibly even demented, because it's important to do that.  But I wouldn't want to be the sort of person who needed care like that.

CHAIRMAN KASS: No, no, no.  Here's the way to put the question sharply.  Let's assume you have enough money to arrange for the kind of care that you will need when you start on your, God forgive me, 10 years of decline into mental enfeeblement, and you can arrange for this in advance.  You've got a lot of money.  Do you arrange to make sure that strangers come into the house and give you your care or that you go to some kind of decent institution and have strangers provide it or do you because of the lessons you want to give your children and make sure that they don't miss out on the opportunity?

Which do you choose?

PROF. MEILAENDER:  The last, the latter of those.

CHAIRMAN KASS: Why?

PROF. MEILAENDER:  Because I think it is the most humane.  It best captures what it means to be human beings, connected in certain ways.

Now always remember with the caveat that came out in the discussion with the friendly interlocutor that all of us can only do so much.  There are limits to what we can do.  Different people are capable of different things and so forth.  But if I've got that much money, which is not going to be the case, I bet I can arrange a way that that can work.  And if I can arrange it, then by all means, I'd do it.  I haven't inquired exactly whether my children think that's a good idea.

PROF. GEORGE:  Leon, what's the argument for the former choice?

CHAIRMAN KASS: The argument for the former choice and I don't know whether this is pride or vanity or something else, but as much as possible to try to preserve the parental/child relation in the way in which it has been, at least until such time as — thanks to the success of medicine — lots of us are going to get a second childhood, not just an occasional person.

In other words, Janet put it in terms of the way in which she'd like to be remembered.  I would put it in terms of the way in which I would like my children to relate to me.  It's a very—there's another Biblical story about the drunkenness of father Noah and his sons.  Some of us have actually had a conversation on this and I think my opinion is perhaps in the minority, but there's something to be said for those sons who refuse to traffick in their father's nakedness and who cover his shame.  Not just for his sake, but also for theirs and, in a way, for preserving the relation there.

And well, I'm not going to be able to do this very well on the spot—

PROF. MEILAENDER:  Surely we are not talking about trafficking in shame of the father's nakedness here.

CHAIRMAN KASS: It's not trafficking, but it's—

PROF. MEILAENDER:  Well, that's exactly what you said.

CHAIRMAN KASS: It's—it is an extremely painful thing, extremely painful thing for children to participate in the degraded life of those they love.  It's an extremely painful thing and the question is whether that's a gift, admittedly, they're going to rise to the occasion.  They will do what they have to do.  The grandchildren will learn.  But I'll put it somewhat starkly.  I don't think one wants to provide as a gift to one's children, even a passing thought, even the opportunity for a passing thought, "Pop would be better off dead."  That's not, it seems to me, the way in which—what it is one wants somehow to arrange things such that they will.

PROF. MEILAENDER:  Remember that the initial piece was stimulated by a discussion about advanced directives.  And one of the things that's always seemed to me actually exceptionally puzzling and in some practical ways misleading about a lot of approaches to advanced directives is that they seem to posit a certain moment in life which is "the real me," the me at the peak of my powers, which moment then ought to be kind of determinative for the rest of life and that seems to me to sort of mistaken in a lot of ways.

Whatever exactly the relation of father to children means, I don't think there's any moment in it that can be posited as the moment that somehow defines what that relationship is.  It has to be lived out and of course, it will be lived out in somewhat different ways, but I don't think I can suppose that a certain moment when I had my dignity, such as it is, fully in hand, in relation to my children is necessarily the moment that can be determinative, or defining moment for my relation with them.  It will have to be lived out and I actually think you're right.  I think it is often harder for the child to come to terms with that than it actually, than it is for the parent, but once again, that's the course of human life and we need to learn it as best we can.

DR. LAWLER:  I agree completely with Gil here and completely with you in this sense.  I agree that I would not want my child to think even for a moment that it would be better if I were dead.  But I also know it's a shortcoming that I think that, because there's an element of wanting more control over things than you can really have.

As if I would want to live my own life as if for not one moment I would ever think I would be better if I'm dead, but in fact, I don't have that much control over things either.  So let's say our impulse is perfectly natural and sort of a shortcoming we share and then finally Gil is right on this.  We're stuck with life not being that neat.

DR. SCHAUB:  In saying that you would never want your child to have the thought that Dad would be better off gone, doesn't that drive you then to have to say that you will have to take it upon yourself to decide when you would be better off gone?  In other words, doesn't it—I mean you going in the home isn't going to prevent them from having that thought.  The only—the only serious thing you could do would be at a certain point, I mean the story Janet tells about some cultures where the elders just disappear at certain moments.  They reach a certain age and they go, some Native American cultures, they go into the woods and disappear.

Wouldn't you have to push it to that?

CHAIRMAN KASS: That is a fair and challenging point.  I guess I'd have to also accept Peter's admonition and it's also at the heart of Gil's own teaching on this.  The limitations of the illusion of control and the ability to master all of these things.

True, we can't control for the contingencies.  On the other hand, we're also not simply reeds that blow in the wind and by arranging things one way, rather than another way, we increase the likelihood of this rather than that, admittedly with imperfect control and with a certain humility.

It's not quite responsive. 

DR. FOSTER:  Let me—I said I wasn't going to say anything more today, but I guarantee you in real experience that there oftentimes comes a wish out of the love for a parent that death would come.  You will continue, if there is no me left, I mean, aware of nothing, we'll take care of trying to keep the subcutaneous ulcers, things and so forth, but it would be inhumane not to say I wish my mother could go home.  You're not going to kill her.  You're not going to withdraw anything.  You'll do everything there is to do, but there are many times, not for your sake, but for her sake that you wish that the time for death would come.  Now you can't plan for death, you know.  I always say, "life is until further notice."  I mean it's interim.  But you can't plan these things.  I guarantee you—well, I can't guarantee anything, but I have seen this hundreds of time.  I felt this for my own mother who was in the last three years of her life, knew nothing.  We cared for her—she was cared for at home.  She died in her own bed.  But there was no mother left there.  There was just a body left which we tried to care for, treated and so forth and so on.  But you long for, you prayed for the release from this which is not life, but extended death. 

So please don't assume that it's something wrong if a child says at some point where there's really no you left, it's like keeping a corpse in a mausoleum, you know, so we go visit Chiang Kai Shek.  It was in the paper this morning, whether they're going to finally bury him or not, you know, and so forth.  It's like a mausoleum that you're doing there.

So it's not evil for a child or a failure of love for a child or a failure of anybody in the family to not wish for the loved one to not have to just be there for a while.

CHAIRMAN KASS: Thank you very much and I partly misspoke.  This is a correction.  Surely when people we care about die after long misery, we feel on their behalf a sense of relief and we're able to say I think without hypocrisy, thank goodness their ordeal is ended.

But what one doesn't want is for the child to come to resent the existence of the parents, not for the parents' sake, but for their own.  And that, I think, is a very different kind of matter.  And one tempts the children with that if the ordeal seems senseless and interminable.  I'm not praising it.  I'm not praising such a sentiment, but human nature being what it is, it occurs.  And it's not a kind of—one would like to avoid having a child look himself in the face and say, I really wish this would end for me, not just for them.  But I take your point completely.

Paul—Charles, to this?

DR. KRAUTHAMMER:  To this, yes.  I would just make one point.  I'm with Dan on this.  I wouldn't romanticize the uplift of care-giving and I wouldn't as a parent impose heroism on a child which I think is what's involved here.

CHAIRMAN KASS: Paul.

DR. McHUGH:  Once again, I don't know how to enter—join up—but I have to say I'm beginning to move away from you all a little bit, primarily because in the process of talking about how tough all this is, you're talking about the stuff that I do almost all the time, every day.

We wrote a book, after all, that became a best seller on Alzheimer's care called The 36 Hour Day because it is—but it became a best seller because lots of people wanted to buy it because they wanted to do it and they come to doctors often, like Dan and me and others saying come on, it's awful and it's happened to you, but I want your help to do what I can to accomplish what's in front of me.  I'm also—so that's one thing.  There are deep ambivalences and we shouldn't be surprised by deep ambivalences in human kindness, that's part of our nature.

The other thing I'm just a little uncertain about is this gradual kind of sense that maybe we're expending a lot of resources on these people and they're not as likely to be as contributing themselves and rich and flowering as other people are, particularly young people.  If we extend that, although I don't like the mountaineering metaphor of the slippery slope, I'm beginning to see its meaning here.  Because after all, it won't be long before if you've followed that too long, you'd be saying well, gee, you know, well is everybody contributing at one level and maybe we ought to judge everybody according to the economics of it.

I'm a doctor and I work as a doctor primarily for my patient and my patient is what is in front of me and my job is to make sure that I stick up for him or her as long as I can and that I shouldn't be taking—I'll let other people, let the economists and other people take into account what this is costing, how many—what the percentage is, all of that.  The patient didn't come to me for that purpose.  He didn't come and say judge me in relationship to other people and decide what I'm worthy of.  He said will you take care of me and I said I would. 

And so I think these exercises, if we go too far in them, will eventually lead us to the point where we don't acknowledge these commitments to each other and that ultimately have very professional responsibilities and could have very bad damages to the society if control and contributions are the only things that get weighed in the balance.

CHAIRMAN KASS: Let me ask Gil if he wants the last word and then we'll break.

PROF. SANDEL:  You don't really mean a last word.

PROF. MEILAENDER:  Is the chair going to say nothing after I'm done?

CHAIRMAN KASS:Other than to announce where we're going for dinner, yes.

PROF. MEILAENDER:  I would just say in connection with sort of the larger project, if we have a project, that we are embarked upon, that the relevance of this discussion, if it has any relevance is in sort of terms that came out in the previous session, whether we'll think wisely and well about policy questions, unless we've learned to think in the right way about certain human relationships and what counts.

That to me, is the connection that will be most likely to make wise judgments about how to deal with overwhelming policy problems if we've freed ourselves of certain illusions, if we've come to think of human life in the proper way and so forth.  I say that without presuming that the way I've described it is the proper way.  I'm simply saying that that's the relevance of the question, it seems to me and why it makes a difference for what we're doing.

CHAIRMAN KASS: Thank you.  I do think that it's very unusual in the discussion of this problem ever to take up the question of what the impending old owe to the others.  We generally look upon it one way and it seems to me an important piece of the discussion is to change the perspective and Gil's very provocative paper enables us to do that in the small and I would certainly underscore his last comment that thinking about it in concrete, personal, familial terms is a perspective that can't be lost sight of if we mean to think sensibly about the larger policy questions, so I do think this is at least a contribution to understanding the diagnosis, to understanding our current situation.

Those of us who are meeting for dinner, could I be reminded of the time, is it 6:30 for drinks.  We're meeting at the Hilton Hotel which is—we've eaten there before.  It's a few blocks down south, I guess.  Yes.  Sort of in the direction of the Metro, walking distance from here.

People who want to walk over there, we can meet in the lobby about 6:25 and walk.  We meet tomorrow morning at 8:30 for a discussion of the paper on the care-giver's dilemma, what happens when patients with dementia have supervening medical problems.  And then the last session we'll have a guest, Professor Burt on public policy questions.  But we're adjourned.

(Whereupon, at 5:15 p.m., the meeting was concluded.)


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