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Thursday, September 6, 2007


Session 4: The "Crisis" in the Ethics and Profession of Medicine: Some Concluding Reflections

Edmund D. Pellegrino, M.D.
Council Chairman

CHAIRMAN PELLEGRINO:  Well, I won't take all the time.  I mean I will not give the remarks that I had in mind.  But I will make a few —

DR. ROWLEY:  The whole point of what I said was that you should give the remarks that you had in mind.  And just go on.

DR. KASS:  I think Janet is right, Mr. Chairman.  I would second what Janet said.  I think we really need to hear it.

CHAIRMAN PELLEGRINO:  Well, let me make a few comments.  First, all crises are not bad.  If you will remember the dictionary definition of a crisis, so far as medicine is concerned, it has to do with an old observation we used to make — I think Dan even may be too young for it, but I'm not — of the patient who developed pneumonia, and we didn't have any antibiotics — I date back before antibiotics — and the patient would go through a crisis.  And the crisis would mean either death or recovery.  And we would always wait for the crisis somewhere between seven and ten days with pneumococcal pneumonia.

I don't know whether you will decide that medicine is in crisis or not to respond to Carl's question of last time.  But let me give you a few crises in medicine, just to raise some hope in this discussion, which has had a lot of — some dismal qualities to it with respect to the future of medicine.

The Hippocratic Oath, which has been mentioned, arose at a time of crisis.  The Greek medical profession was in total disarray.  They were considered mostly quacks and money grubbers.  And the Hippocratic physicians who created the Oath stepped back and said, "No, we don't want to be like those people."  And they developed an oath of commitment.                

Let me give you two or three more of those, and then I'll move on to what I want to say.

A similar situation occurred in the first century A.D. when the word "professio," the first use of the word "professional," which we've been throwing around here today, was made by the physician of the Emperor Claudius. 

And he talked about "professio," the Latin word, strict word, of a commitment to what?  The Hippocratic Oath.  And he made it in a treatise which was dedicated to the fact that giving medication to people would be in their interest, but he justified it in terms of the profession of the physician, the promise, the declaration — that's the etymological meaning of the word — was in fact to act in the best interests of the person.  And at that point, people were not doing it.  So that was a reform.

1803, the reform of Thomas Percival — when the physicians of the Manchester Infirmary were in a state of tremendous strife with each other — the Thomas Percival Code, which is the basis of the AMA's code. 

In 1847, the medical culture in the United States was in a terrible state of distress, with the same kind of nonsense that was going on with the Greek physicians, and we got the AMA Code of 1847.                 

You're all familiar with 1910, when Simon Flexner had the comment on the dismal state of American medical education, 450 schools, and the conception of scientific medicine was a single microscope, which usually wasn't in very good operating condition.

I think we're in a similar situation now, where the profession once more is in a state of confusion and identity in its relationship to society, its patients to itself, and so on.  And I'm hopeful, can you imagine, in the face of all of this, that we may get another kind of reform.

Professionalism is one of them.  I do not think the Physician's Charter is the answer.  I think the Physician's Charter is admirable.  It describes a series of characteristics, of attributes — ten of them, as a matter of fact — which we should have.  But unfortunately, it is ascriptive, it is descriptive, it is not argued.  And medicine is at essence a moral enterprise.  It may not be conducted that way, but there's no way of avoiding it.

And let me then pick up that theme and carry it a little bit further in relationship to what is happening.  Now, you will find a lot of this in the paper I submitted to you, and I don't want to repeat that for you. 

But fundamentally, I think if we are ever going to understand what's happening, it's going to have to be in terms of what makes difference in medicine.  What kind of human activity it is which makes it different from other human activities.

Not that other activities haven't the same kinds of dimensions of morality put on them, but in medicine they are specific.  And that goes to the fact that each and every one of you is going to be on the gurney one day.  And I'd like you to put yourself in that position, if you would.  You're on the gurney.

You may be healthy now, but I assure you, I'm sorry to say it, you're all going to be lying flat.  And there's something about the horizontal position as opposed to the upright position that I've discerned in 66 years of medical practice that makes a difference in the way you look at the world.

And so I've concentrated in my whole notion of how medical ethics has a special characteristic, which people have been pleading for, it's related to what will never change, as far as I'm concerned.  When you are on that gurney, you're no different than the sick patient Hippocrates had, than the sick patients we have today, or, I can assure you, when you get on the starship to Galaxy 999, it's going to be the same.                         You're going to be dependent, frightened, anxious — each and every one of you, no matter how intelligent, no matter how courageous you are, you're going to be in need of help.  I use the word "healing" without apology. 

You will need healing, "healing," being made whole again, which is what the Anglo Saxon word means.  Whole again to the extent that we can do it, obviously.  Not completely, but to try to repair, help, care, and when we can't cure, to care, to comfort.  You're going to need that.

Now, in that existential state, I the physician come to you and I say, "Can I help you?"  "What can I do for you?"  What are the expectations you have when I do that?  You have at least two, I feel, and I think you wouldn't disagree with me on that.  One, that I'm competent, or the whole darn thing is a lie, my offering to help you, to heal you.

And the second one is that I'll use it in your interest and not my own, and I won't exploit you.  Now, you will say, "Well, this is terribly, terribly fundamental.  It's obvious."  It's so obvious that it's painfully the thing that's most frequently missed. 

Because, profession — go back to that word "professio" of Scribonius Largus and those before him, that act of profession is a promise, a public declaration, in terms of the Latin etymology of that word, which is still important, that I have the knowledge and I offer it to you, and you have the right to expect me to use that in your interest.  And that is the bond of "professio."  That's what a profession means in medicine. 

In law it's another thing.  In law they come to call and they're looking for some repair of justice.  And he promises, too, to take their case.  The minister deals with this.  So what I'm saying is common to other professions. 

I'm not expecting uniquely to medicine, except that in medicine we have the most intimate of human relationships, except those of husband and wife, which you mentioned.  And friendship, perhaps.  But nonetheless, one in which you must bare yourself.  You've got to take your clothes off.  You've got to bare what's going on in your mind.  You've got to tell about all the nasty functions of your body.  That's a relationship that doesn't exist elsewhere. 

Ben has it in one dimension of his life.  I as an internist have it in most of them.  I can't do what Ben can do to heal, but also, I can, on the other hand, fulfill that compact.  So it's a covenantal relationship.  And therefore, I think the obligations of medicine arise from that. 

Fidelity, trust, that's being a professional.  Competence, that's being a professional.  That's why those adjectives are listed.  But I find it unfortunate they're listed as an answer to the problem by ascription, by assertion, without moral argumentation.  So I'm looking for a moral foundation for, if you want to say, re-professionalization.

I don't like the term "professionalism."  To me it has a connotation of belonging to a group, a loyalty to the group, a certain amount of elitism that we are professionals.  I want to say the professional is the one who makes an act of profession to another human being to act in something other than his or her self-interest.  And de-professionalism means a default of that promise.  It means failure to keep that promise, and that's where the difficulty arises.

So that when you do come to the Botox dermatologist that was mentioned, that's really a failure.  Now, therefore, from my point of view, what can we do?  This is what you're asking, how we can change this?  I don't think any program is going to change it.  I don't think any system is going to change it. 

I believe, with those of you who have raised questions about an educational program, yes, it's useful, raise sensitivities, et cetera.  But I have been teaching for 65 years to medical students, and so far as I'm concerned, to learn something about this in the first two years of medicine is hopeless.  It has no connection for them with reality.  Third and fourth year it begins to impinge on them.  And the residency is when it really, really happens.

Now, I don't want to go into all the details of how one might teach it.  I have to shorten my comments.  We are at 5:00 o'clock. 

But I want to summarize by saying we have not, in today's discussion, gotten to the core, which is the human relationship, the very intense human relationship, between someone in this very vulnerable state, this exploitable state, eminently exploitable state, who has to come to another human being who declares that he or she has knowledge to help them, invites trust, pleased, obviously — whenever you're cornered, we're all pleased — to have Jordan come and put those words down. 

But I mean those words.  And all of those are charged with moral obligation.  And what I would argue is that the obligations to the profession are entailed, if I can use the philosophical sense of that, entailed by the reality.  So I'm seeking for the internal morality of medicine.  Not that which is attributed to it, but entailed by the actions we take, by the way we live at the bedside. 

Just one final comment.  Don't jump to the conclusion that that means that I am ignorant of the social responsibilities.  But I do think there is an order of priorities. 

When I'm locked to you in that covenant of trust, when I said, "Can I help you?" that's a covenant.  It's something more than a contract.  It can never be a contract.  How can there be a contract — I'm saying this to the lawyers — between two people who aren't equal?  Not unequal as human beings, obviously, but in their existential state. 

When you're lying on the gurney, that's a different situation in which to be.  It cannot be a contract.  You say, "I want a contract."  Well, what do you want a contract for?  You want to be helped, that's what you want.  I have promised to do it, having engaged trust, fidelity of trust — I won't go into all of it. 

That's why I talk about the virtues, the moral agency they talk about in general terms.  It has to be spelled out, spelled out in intellectual and moral virtues.  Well, I don't mean to lecture you.  I'm just pointing out the thoughts that were running through my mind as I heard the discussion. 

I'm being perhaps a little critical, but I think what they're doing is very important.  But it's not going to catch unless it's got a moral force, a moral impetus behind this, because we're in a moral relationship.  And that's not the only one, and not limited to medicine.  But it happens to be very acute in medicine.  Think of yourself on that gurney, and then you begin to understand what I think about medicine and what we're committed to.

Ben, that's where I heard you say, "It's not my patient."  That's right.  That doesn't exist today, where you change at 5:00 o'clock and somebody else comes on.  We know that has to change a little bit.  But nonetheless, when I see someone, you are my patient and I am your doctor.  Why?  Because there is a certain covenant between us that can't be eradicated.  You've entered into it.  I can't wipe it out at 5:00 o'clock.

Well, let me stop.  I don't mean to make a passionate plea for a profession which is having its problems today.  It's having a crisis.  I really hope that that crisis, and I believe that crisis, will emerge in another state of reformation.  What it will be, I don't know.  But I think it's going to be crucial for all of society. 

Which leads me to a point that I do think it should be a matter of concern for this Council , because we are moving quickly from these moral questions unresolved to resolution in legislation and in policy.  That's not the best way to do it.  But let me stop.

Yes, Leon.

DR. KASS:  The first thing to say is thank you, for that very articulate and moving account, and also for the paper which we were given to read which represents, for any of you who know, Ed's work over the years.  It's just a distillate, a wonderfully rich account of the medical profession, beginning phenomenologically, what it is to be sick and what it means to offer the helping hand.

And I have to say, I don't dispute the importance of the other things that we've been discussing, either at the last meeting or the earlier sessions of this meeting. 

But this does seem also to me an irreducible starting point for thinking about, not professionalism, but thinking about the medical profession and how it is healthy and rightly practiced.  It seems to me right to begin phenomenologically with the relation of the sick and the healer who offers the healing hand. 

It seems to be right to emphasize, at least to focus on the question of what is the good to be sought.  And you and I might differ about how many of those four levels of good operate and in which way, but that's a family quarrel. 

To put the teleological question, what are you trying to accomplish here?  What is the goal?  And therefore, in relation to that, what are the, not only what are the intellectual skills that are needed, but what kinds of traits of character and what kinds of powers of discernment and judgment — you call it "prudence," I think, rightly — are required to fulfill the implicit, and maybe even explicit, covenant that once upon a time taking the Oath might have meant publicly, and which is tacitly present in each doctor-patient encounter, even though no one has to say, "I hereby profess medicine, and all of those things that go with it."

I think this is the first paper that's seemed to me to put the center where the center belongs.  And I guess — I mean, I've got a lot of questions, but maybe this would be useful:  to invite some connection between these central matters and the kinds of things about which all of our other presenters have been speaking, where they seem to talk about the external constraints, and some of them not only external, but certain kinds of things having to do with the growth of medical knowledge and specialization, things of that sort, how one would begin to think about the preservation of this profound understanding of what it means to be in the healing professions in relation to these kinds of constraints that make this difficult.

You say that certain kinds of virtues are entailed.  Well, they don't automatically follow, if by "entailed" it doesn't mean that if you have the covenant, you necessarily get the virtues.  It means if you want to fulfill this covenant, you will need them. 

And the question is, how in the present age, under these circumstances, should we begin to think about making this view of the profession vivid to the rising physicians, this view of medicine vivid to them in the face of all kinds of other things that suggest, and not wrongly, that there are systematic constraints, there are systematic deformations, there is the question of access, there is the question of distribution, there is the question of specialization, there are the deformations that the reimbursement scheme produces, of how much time you can spend finding out what's going on. 

So, for those of us who like this, how do we begin to talk about this in relation to those things which are the most common and loudest complaints?  If I understand you — and I'm sorry to go on so long, but I think this is really very important — you seem to be saying that there seems to be an insufficiently clear understanding within the profession itself, or insufficient articulation of what's tacit to the profession itself, of this kind of central core.  And that if you wanted to begin a kind of reform or rejuvenation, you would begin with focusing on this.

These other people are saying, "That's not the problem.  The problem is this can't go on except with that."  And I guess I would invite you to try to connect this to the other conversations that we've heard.

CHAIRMAN PELLEGRINO:  Thank you very much, Leon.  As you know, coming from you, I particularly appreciate that.  I do think this is — the problem is that we don't have clinical teachers anymore who really believe that the heart of the matter is at the bedside, and is with the sick patient.

Now, those who are not sick always say, "Well, you're always worried about sick people."  But I go back to Hippocrates, the first line of his treatise on medicine, which says, "Medicine exists because people become ill."  Simplistic statement.  That's why we're here.  We have public health positions.  We have a responsibility to be involved with the larger prospect of what we do, in catastrophe and war and so on, we place the common good first.                

But there's something, I'll use the word,  "sacred" about my committing to you in that situation of dependence that you find yourself on the gurney.  I don't know how to communicate that except to say it.  I can teach it, at the bedside, because this happens with every encounter.  You don't have to wait to have something designed. 

Every encounter, whether it's very serious or not, I can tell you this, as a physician for a long period of time, that there is no serious illness that doesn't present a spiritual crisis to the patient.  Spiritual not in the sense of religious, but a confrontation with one's own finitude, and that's the extreme of the vulnerability that a sick person can go through. 

So I don't know what to say, Leon, except that happily, when I talk about this, just to raise you, give you a little more optimism, when I talk about this, at least 25 percent of the audience will come and say, "We're so glad you said it.  Somebody needs to say it, to reinforce this.  This is what we really want to do, but we can't do it." 

And that goes back to the question of whether in fact the instrumentalities and organizations of society — we cannot escape moral accountability, is the other part of that relationship.  You've made a promise; you're responsible, now, obviously, in varying degrees of mitigation of guilt.  But that's not the same as being responsible for an effect on the patient which is deleterious or a violation.  That's all I can say.  Forgive me for the heartfelt presentation.

PROF. LAWLER:  Well, sir, we have every reason to be proud of our Council members, because compared to our — I thought our speakers, although very eloquent and passionate, spoke too abstractly about psychological and moral distinctions. 

And I'm not making this up, because almost everyone on that side of the table, on that side of the room, complained — Carl, the most at length, but also Gil and Diana.  Whereas, your presentation, by contrast, was so rich and concrete, because you're using the full array of moral and intellectual virtues of Aristotle.  This is a good thing.  I'm all for this. 

Nonetheless, someone might say, is it the job of the United States government to reconstruct or an advisory body of the United States government  to reconstruct the ethics of the physician along Aristotle's moral and intellectual virtues? 

Now, arguably, we might have snuck that stuff in in previous reports.  But to do that straight out might raise some eyebrows.  Because there's a reason why these fine men and women speak so abstractly.  That's the way ethics is nowadays.  That's the way ethics will tend to be in a rights-based society. 

So this would be a genuinely radical challenge, not only to your profession but to all professions, in the way we think about ethics generally.  And that would require that we all raise ourselves to your level of ethical expertise and detailed knowledge of Aristotle.  So, I'm up for it, but it would be tough.

CHAIRMAN PELLEGRINO:  Thank you, Peter.

DR. FOSTER:  Can I follow up with that, and Leon's statement?  I mean, let's say you think that professionalism is something that should be continued by the Council and some sort of a report brought from it.  But one of the things that Leon mentioned was connections, and you just did the same thing, Peter, and so forth.

I mean, if you follow up on Peter's statement that if this is an advisory Council on the greatest bioethical, politically bioethical, questions facing the country and the Council is not fundamentally related to physician failure and professionalism and so forth, but has to do with the issue of a system that does not take care of its people — and two or three people have said this today.          I mean, you're not going to have an answer to the delivery of healthcare and the coverage system. 

But it seems to me that one way you could, if you didn't want to just come out and say that we don't have a solution to the problem, but we believe that the number one — and everybody in the presidential thing is talking about it — but that we think that this problem needs to be dealt with.

And one of the ways you could conceivably venture into that is to say that it's even having a huge problem on the professionalism issue of the physician, even there.  Now, that's sort of a fake way to go at it.

But I still am worried about the fact of every — I don't know about you all, but the question that I get most often is what is the Council doing after the stem cell thing?  I mean, for people who don't know what we've been doing.  And they all say, "Why don't you say something about healthcare?"

It seems to me that in the professional, at least in my medical school and other places, that that's the question that I get most often.  "Are you afraid to deal with this because it's political" or whatever, and I think that's a question that really ought to be addressed.

I mean, it would be of the seriousness that was involved with some of the other things that the Council has done.  I don't know.  I mean, the Chairman speaks exactly what I feel about medicine, and I think everybody here feels about that, too.

But I think Peter's point is sort of an interesting one.  You've got two more years to go on the Council , and so you say you've spent eight years and you've never said one word about the issue of justice and mercy in terms of medical care.

If you live in — I'm lucky enough to live in Dallas, where we have a great hospital for the poor.  The political community, both the commissioners' court, the counties, agreed to raise taxes.  They want to raise $1.2 billion for a new Parkland Hospital to take care of the poor.

I mean, that's a community that's — 1.2 billion is a lot.  And the school district wants 1.2 billion for new schools.  But I'm a little concerned, and maybe I'm the only one who gets that question.  I got a lot of questions about our report on organs and so forth, about what are you going to do?  It's now up to 97,000 people waiting, you know.

But I just think we ought to really address the question, are we going to avoid this?  Now, the problem is that we don't have the expertise and can't get the expertise.  And there are people, economists and everybody else who know far more about this. 

I'm just thinking about a moral pronouncement about an ethical problem, a moral pronouncement, not a solution.  But saying that the country — that we believe, as a body assigned to ethics, needs to address the question. 

And we know that it's in the political thing, but let's say whoever comes in, it might be useful to — maybe because this Council was formed under President Bush, that anything we say, if it's a Democrat that's elected, doesn't want to have anything to do with what we say. 

But I do think it would be worthwhile to have a sentence or two before we adjourn — and I know it's late — but whether we ought to look at that.

CHAIRMAN PELLEGRINO:  If I can abuse your patience for a minute or two further on this issue.  I also feel — I've been talking about the individual physician.  I also feel that the profession of medicine as a community is a moral community.  Now, a moral community is not a comment on how they behave, but on their obligations.

And I think that while our first obligation is to the individual person to whom we've committed ourselves, is to that person, there are other levels, three more levels, in the way I develop it.  Because we took an oath of committing ourselves to something beyond self interest when we took that Hippocratic Oath.  That was the real essence of it, from the point of view I'm talking about.  We did it together.  We're responsible for what each other do.

We also in that have declared over and over again, in the preface to the AMA's Code of Ethics, that we are interested in the public.  Therefore, the moral question comes up, what does a good profession or a good society owe the sick, those on the margin?

I think it is a major question, and I think the two go together.  And I don't think we can consider ourselves moral professionals unless we are involved in some way.  And again, I don't want to take you down the pathway of the things I've written.

But I do feel that that's part of the same kind of commitment that I'm talking about.  Excuse me, Gil.

PROF. MEILAENDER:  I'd just ask you to clarify something.  Is your question what your profession owes to the sick, or is your question what the rest of us owe to the sick?  Because, I mean, those are different questions.

CHAIRMAN PELLEGRINO:  Yes, yes.

PROF. MEILAENDER:  And it seems to me that most of the time we start with the question of what your profession owes to the sick and it turns into a question of what the rest of us ought to make possible for your profession to do.

And I think the rest of us do owe something to the sick, but I'd like to sort those questions out a little bit.

CHAIRMAN PELLEGRINO:  You know, I take that distinction, but I think we should be leading, because of our close relationship to the human being in the existential state of illness. 

I mean, that's what we're talking about when we talk about the healthcare system.  We're not talking about a system.  We're talking about a group of human beings who we know, and they're in that vulnerable state and not having access to what we think, out of mercy, or love, or whatever, we should be providing them. 

I feel we have a moral obligation.  A good society has a moral obligation.  Now, if this group wanted to go down that line, I would love to go down that line and explore it further. 

Yes, Gil?

PROF. MEILAENDER:  If I may just push once more.  I don't doubt that — I mean, I'm not sure about this "leading" metaphor.  You asked us to put ourselves on the gurney.

CHAIRMAN PELLEGRINO:  Yes.

PROF. MEILAENDER:   Where we will all be someday, or someone else whom we love deeply.  So, the question of, sort of, who leads in this discussion, whether the medical profession leads or whether we as citizens lead seems to me to be a worthwhile one, also.

CHAIRMAN PELLEGRINO:  Oh, I absolutely do, because I think that when I speak to non-physicians or the general public on this, about the state of the healthcare system, I've said, "You get the healthcare system you want, and what you have is what you want in the United States until you change your notion of what the moral obligation of this society, if it's a good society, is to the sick, the poor, the on-the-margin.                        

Now, I sound like I may not even belong to this group, but that's my view of the matter.

PROF. GEORGE:  Dan, let me say what I think the problem is, and perhaps you can respond.

There are moral positions that would dictate a policy, generally speaking, if they were adopted.  For example, someone who, as a moral matter, believes in strict libertarianism, would want an entirely privatized system in which there was minimal government involvement, and would be prepared to tolerate any consequences, as far as the inaccessibility of some people to healthcare services, because of that moral commitment.

Another example would be strict socialism, where someone who just believes in that as a moral matter would say, "Look, we should have a government-run healthcare delivery system because that's just the right thing to do," and that would override competing considerations.

So, yeah, in those cases, if you happen to hold a view like that, then the matter is sort of dictated before we get into the details of the costs and benefits and tradeoffs and consequences of different opportunities, opportunities falling outside the bounds of the particular view.

But I suspect strongly that most people on the Council are like most people in the country, most people in the Congress, neither strict libertarians nor strict socialists.  Rather, they are people who believe in the dignity of each and every human being.  They do not want to see people suffering or deprived of healthcare when they are in need.  But they're not committed to a moral conception that will dictate either a pure free-market system or a pure socialist system.

They would have that policy judgment be made on the basis of a whole lot of factors that certainly are considered within a moral framework, that includes a commitment to the dignity and profound worth of each individual human being, but where what's actually going to generate the conclusion would not be moral considerations just as such.  There would be economic considerations, questions about what tradeoffs we ought to be willing to make, efficiency, just lots of factors that would have to be deliberated about, and about which reasonable people can disagree and about which, at least in some cases, I think wouldn't be a single uniquely correct answer. 

They would be different people making different tradeoffs, or judging different tradeoffs differently, which means I think that the most we could say, unless we're prepared to go with a view that — a moral view, libertarianism or socialism or some other one that would dictate the answer independent of considerations of efficiency and tradeoffs and so forth.  The most we could say is I think what you were calling a moral pronouncement.  But it would have to be a pretty general moral pronouncement.  And maybe this would be sufficient from your point of view. 

But it would have to be something as general, it seems to me, as "We believe and we know our country is committed to the proposition that each individual human being has a profound dignity, that life and health are intrinsic and great human goods and should be respected and advanced in people and never directly harmed, that we therefore find it a very bad thing indeed that there are many, many, many people, a high percentage of people in the country, who do not have insurance to cover the kinds of needs that they could very well and often do experience.  And this is an issue that's got to be dealt with."

Someone's got to.  We have to do something about it, but we can't say, because we haven't gotten into the non-moral considerations where we don't have any particular expertise to say.  No one can say whether it should be basically a market system, basically a government system, or some mix of the two; and if a mix of the two, at what level they are mixed.

And that leaves me wondering whether such a statement could rise above — and I'm open, so tell me if you think it can — could rise above the platitudinous. 

See, I think when it comes to other issues, whether it's embryonic stem cell research or certain sorts of operations that are not medically indicated, Botox or what have you there, I think there are moral considerations that would lead at least some people, large numbers of people, to think we can resolve issues like that and have something important to say on issues like that, or at least marginal to relevant moral considerations before the public, to resolve the issue. 

But with the general problem of access to healthcare, I don't see it as the same.  Can it rise?  Could we make a statement in your view, Dan, that would rise above the platitudinous?

DR. FOSTER:  I don't know.  I don't know.  It might just be a platitude.  I mean, I have no idea that it's a platitude.  Well, we certainly can't do the methodology, you know, you could have a basic health system for the masses and a free system above  —  you know, there are ways that you could do it. 

What we know is that essentially every developed country in the world has made a decision that they're going to take care of the people who are ill in the country.  And we have, for a very long time, not had that thing.  It increased, according to the latest census, another 6 million people who are uninsured.  So I recognize that it might be a platitude. 

But some very smart people, people like Seldon and people who have thought about this, and so forth, say that they think that it might be an enhancing thing for the Bioethics Council to say "This is a crucial problem to solve, and that we as a society need to do that."  And it may just go off into the air.  I have no idea. 

I do think, and I don't have any statistical thing, I'm just telling you what people talk to me in the hall about, "Why have we not had a word about this critical thing?"  And I think it might be worthwhile for us to say, if nothing more, that this is a crucial thing that needs to be dealt with.  I mean, we've talked about enhancement, we've talked about all sorts of things that the bulk of the country are not.  You know, it's an intellectual problem and it's an ethical problem. 

So I don't know, Robby.  I think you're, as usual, right on the mark.  And I don't know.  I just — because I just felt like after we've been talking, spending all this time on professionalism and so forth and so on, and it's impacted by these things, as Leon just said, and Ed said.  I don't know. 

We'd have to decide whether that's — the Chairman has said he thought it might — I think I heard him say he thought if we went down that road he would be enthusiastic about it.  And just the fact that we — I don't know.  It might just be steam.  I don't know.

CHAIRMAN PELLEGRINO:  I have Carl, Rebecca and Bill.  And I just want to respond quickly, Robby. I fully agree, though on the methods of getting there and the intricacies of the system, there are going to be people of good will differing enormously.  But I think if somebody could come out and say, whatever we do, it's got to be driven from ethics.  The ethics drives the system and the economics, rather than the economics drives the ethics, that would be a tremendous advance.  And I think that is appropriate for a group like this.

Now, let's hear Rebecca, Alfonso and Carl.  And also, we're under the threat of having to evacuate this room at 5:30.  (Bell sounds.)  Wow.  But if you can do it quickly, go.  In that order  —  Rebecca, Alfonso and  —

PROF. DRESSER: Well, I've got the same question that Dan gets quite a bit.  And I've been asking that question for quite a while, and I know quite a few other people on the Council have.  Why aren't we doing something on this issue?

I do think we've tried to say some things about it in the "Taking Care" report.  But I would  —  as someone who was recently on the gurney, I have trouble saying it because of the reason why I was.  Really, the description that you gave is so powerful.  And I think it doesn't necessarily require highfalutin Aristotelian stuff, although that would enrich it, but it really would resonate with many, many people on a personal level and would take us down to the ethical, moral heart of the matter.

And then moving upward, it would be possible to connect certain problems that have been discussed, such as, some people, when they're in this very vulnerable position, all they can do is go to the emergency room and wait around in the corridor and suffer.  And this is an ethical problem.

Now, we don't have to say, "And here are the nuts and bolts ways to fix it."  That's what everyone else is talking about.  But if we could boil it down to a core presentation of the harm that this does, I think that that could be powerful and useful.

PROF. GÓMEZ-LOBO:  Repeating a little bit, I would ask Robby, what's wrong if it is a platitude?  I mean, it is true that we cannot go into specific solutions, but platitudes are self-evident truth, all men are created equal, stuff like that, and need to be said precisely because they have not sunken in.                        I'm amazed, for instance, when I talk with Europeans or with Latin Americans.  They are simply amazed that Americans accept the fact that there are now — what is it?  47 million people without health insurance?

DR. FOSTER:  The figure I remember is 46, but —

PROF. GÓMEZ-LOBO:  Well, they said that it increased by 6 million.  So I see a value in making this statement on the part of the Council , even if it is platitudinous.  Simply for the reason that if it sinks in in the American public, if it reaches the Congress, you know, as a kind of moral pressure on them to seek a solution, or the next president, I see it as an important thing, even though it may be a platitude.

PROF. SCHNEIDER: I certainly agree that it would be silly to spend time trying to think about what the right kind of system would be, if only because I think the right kind of system is whatever system could be politically possible.  Almost any system that achieves the end is going to be better than giving up on it altogether.

It may be a platitude, but it's a platitude that gets lost track of a lot.  It gets lost track of by bioethicists, who rarely interest themselves in it.  And it's a platitude that gets lost track of when we have discussions about how to reform the healthcare system, because those tend to wind up being discussions about how this is going to affect my ability to work with my doctor, and so on. 

So I think it is at the very least a platitude worth repeating and a platitude that's actually true.

DR. KASS:   I have, I guess, mixed thoughts about this.  The importance of the issue is, I think, evident to everybody in the room.  The question is, what would the useful contributions from a Council like this be?  When some of the bioethicists who are interested in this subject actually start to speak about it, they think that the grounds of the justification for doing something are self-evident.

We've heard "social justice" repeated many times.  It must have been Peter, I guess, who raised some question as to whether people who use this as a shibboleth have thought five minutes about the very meaning of it.  Because they seem to use it as a slogan as if it's sort of self-evident.  And it seems to mean something like equality.

But it does seem to me it might be a useful thing to articulate the ground of doing something about this, not just the outrage that there are people who don't have care.  But it's one thing if you go at this in terms of people have a right to something and therefore others have a correlative duty; it's another thing to say that healthcare is a social good and therefore it's a matter of distributing the social good, and it's a problem with distributive justice.

Neither, by the way, not that it matters, would be my preferred way into this thing.  It's another thing to ask the question of how should a good society think about the needs of its least fortunate members, and do something not only for them but in a way for all of us?

And it does seem to me this isn't going to solve the problem.  But there would be a way of articulating the different kinds of justification, and even to argue for the better ones, what we think might be better ones.  That might be a contribution and a way of highlighting this subject, and not merely screaming about the outrage and quoting the numbers.

Or — and here I would underscore what Gil said — it's one thing for doctors to say, "We can't practice medicine the way we would like to practice" when — and this was 45 years ago, at the University of Chicago Hospitals, if the guy didn't have insurance in the emergency room, you hung up an intravenous and sent him to Cooke County.  And that was a terrible thing for a young medical student to see.  That's one way to answer the question.

The other thing is the question, if you really start from the good society and ask what it owes, you'd have to then think about what it owes in education, you'd have to think about what it owes in terms of public safety and various other sorts of things.  And then the question becomes much more complicated.

So I do think there's something to be done here, if we're willing really to treat this as a question rather than as a slogan.  And I think it would be very important, because the sloganeering only gets people's backs up. 

And if we put some serious thought into this and try to articulate a principal defense for doing something, and a good diagnosis which does more than say, "There are these many uninsured," without breaking it down, and things of that sort, then I think there's a real benefit here.

CHAIRMAN PELLEGRINO:  And that will have to be the last comment, because we are in violation of contract for all the time we go over 5:30.

PROF. GEORGE:  At least it's not a covenant.

CHAIRMAN PELLEGRINO:  Bill?

DR. HURLBUT:  I just have a few reflections.  I think maybe it's good to get them out, since this is the context of our larger effort.  It's not a direct sequence to what was said here about the social/political dimensions. 

But reading your essay and reflecting on what Leon said about the personalism of your articulation of the notion of declaration of professionalism and its personal covenant and how they might connect with the broader social engagement and social responsibility, it strikes me that there are a few things worth saying.  These may sound a little abstract, but I think there are tangible ways we could articulate them.

One thing that — and I don't know quite how to even say this.  But I feel as if, as a physician trained in what I consider to be a very privileged kind of encounter with humanity, seeing people on the gurney is like nothing else.  I think because of certain social factors, we've become overly self conscious and somewhat dishonestly humble about what we — who we aren't. 

And I think there's a sense in which we might be able to say something about what we are, or at least what we ought to be, given the privileged encounter that we have in medicine.  And so in an idealized way I'd like to put out just a few things about that, quickly, and we can come back to them some other session.

It seems to me that as a physician, we have a very unique appreciation of the psychophysical unity of the human person, that we understand that what a person is is to a certain extent a product of forces that they didn't choose, that they inherited genetically or circumstantially.  And that's a very strong root of compassion that I think only a person trained in biology can really plumb.

Second, I think we see the fragile balance that the psychophysical unity means, that there is a danger of its disruption, and therefore, we have to be very careful what we use the new powers, especially as we gain powers through biomedical technology, what we as a profession use our powers for.  That there is a connection between our biochemistry and our personal and spiritual existence that we should not disrupt.

Third, I think that we have a privileged encounter with what you articulated, the frailty and finitude of life, and that therefore, a sense that life isn't always about what you might think it's about if you're just watching television.  That life is a very serious journey, and that sooner or later, whether we want to face it or not, we will see it from the horizontal as a serious matter.

And this gives us a particular relationship with the reality of suffering, and a role that I'm very aware of.  My wife is a pediatrician, and she comes home some days and is very drained, and needs a little kind of lifting up, and she's very strong.  But it keeps reminding me of what I know from my own experience as a physician, that we do more than just diagnose and treat; we also absorb.

We absorb an awful lot of fear, we absorb frustration, disappointment in people's lives, and even anger, and that this is an intrinsically self — not just self-effacing, but self-draining, in a way.  Something — it takes a lot out of you to encounter this.  And yet it's a very great giving.  There's an implicit kind of sacrificial relationship that's involved in this profession.

And finally, I think that — I don't know how to even articulate this.  But it's very plain to me that medicine as a profession is a profession because it has a limited prerogative.  It isn't about everything.  We are not going to properly ever relate to our larger social engagement properly, in my opinion, as engineers, nor are we ever going to really be a substitute for priests and their equivalent in various languages.

And finally, it struck me as one of our speakers was speaking about the White Coat Ceremony — it struck me that — you used the word "sacred," I believe, earlier today.  It struck me that it's very interesting this is a white coat; it's not plaid, it's not striped, it's not paisley.  There's something about the white coat.  There's a kind of a purity — is that the right word?  There's a kind of trueness in it, a nobility, a dedication, and a mercy to go along with being a physician.

There is an effacement of self-interest, as you said.  But you made an interesting statement in your paper.  You said, "This is not to demand absolute or heroic activism more than is expected of nonprofessionals."  And yet, there is a special role here, and that strikes me as modeling a dimension of reality that isn't plain to the average person. 

So whether we're more dedicated and more sacrificial, no, that's not the point.  The point is that ours is a very special role, that we model in this arena where these kinds of issues are so vivid and evident, deeply personal, deeply vulnerable.

And this unequal relationship does give us a special, a privileged understanding that we don't need to apologize for, but that we need to live up to.  It makes failure more troubling, obviously, when it's unethically conducted, but it also makes a competent and compassionate profession all the more powerful.

CHAIRMAN PELLEGRINO:  Thank you very much.  Well, thank you all for your comments, and I appreciate it very, very much, and allowing me those few moments, those few quick remarks.  Thank you.

(Whereupon, the proceedings in the foregoing matter went off the record at 5:48 p.m. to resume the following day, September 7, 2007 at 8:30 a.m.)


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