Transcript, Meeting 25, Roundtable Discussion and Closing Remarks

Date

May 3, 2016

Location

Washington, D.C.

Presenters

Jason L. Schwartz, Ph.D., M.B.E.
Assistant Professor of Health Policy and the History of Medicine
Yale University School of Public Health

James Childress, Ph.D., M.A.
John Allen Hollingsworth Professor of Ethics
Department of Religious Studies
University of Virginia

Michael S. Gazzaniga, Ph.D.
Director, SAGE Center for the Study of Mind
University of California, Santa Barbara

Nandini Kumar, M.B.B.S., D.C.P., M.H.SC.
Former Deputy Director General Sr. Grade
Indian Council of Medical Research
Dr. TMA Pai Endowment Chair
Manipal University

Tom L. Beauchamp, Ph.D.
Professor of Philosophy
Senior Research Scholar
Department of Philosophy and Kennedy Institute of Ethics
Georgetown University

Ruth Faden, Ph.D.
Andreas C. Dracopoulos Director and Philip Franklin Wagley Professor
Johns Hopkins Berman Institute of Bioethics

Manuel H. Ruiz De Chávez
President, Board of Directors
Mexico National Commission of Bioethics (CONBIOÉTICA)

Patricia King, J.D.
Carmack Waterhouse Professor of Law, Medicine, Ethics, and Public Policy
Georgetown University Law School

Transcript

ROUNDTABLE DISCUSSION:

DR. GUTMANN: Okay. I'm going to get us started, and I hope Manuel will – because we have a hard stop at three o'clock (3:00). First of all, I want to reiterate thanks for your helping us reflect. And our purpose is actually a practical purpose, which is to think about what advice to anyone who's willing to listen – this is a case where it's not primarily, in fact it's not, our wonderful President who we're very honored to be serving – but this is something that and we don't expect to issue a report. But we may individually, or I may write something that reflects our reflections with advice to be taken or left as any future Administration or commission wishes.

DR. GUTMANN: And so what I'd actually like to ask you, as Nita so astutely looked into her crystal ball, prescient, as all of our Commission Members are, is what one take-away would you suggest for future bodies like our own? And it could be anything from the structure to the content to the way – one of the things, and I'm not suggesting you have to say this, but I just need to put it in: the way we communicate, which has changed dramatically. I mean, we have webinars and everything like that. But just one take-away from your reflections on what you have done, what you have studied and observed, and the context that we're in, what – and Manuel, welcome back – what one take-away would you want to impress upon us that would be relevant for future bodies, whether they are structured like ours is or structured differently?

DR. GUTMANN: But bodies of – and I would ask Manuel and Nandini, because we have your great insight and intelligence, if you would reflect on what you would see as helpful for an American bioethics commission. Because it is – the tradition is to make sure there is some national body whose exclusive mission, however broadly or narrowly defined – it's going to be about bioethics. And so I'm happy to begin with whoever's ready to begin, but I want to hear from all of you. Tom, your light is on so I'm going to call on you. And then I'm just going to jump –

DR. BEAUCHAMP: I'll just turn the speaker off.

DR. GUTMANN: It's the equivalent of making eye contact. (Laughter.)

DR. BEAUCHAMP: I'm not sure exactly what you have in mind with the take-away, but let me sort of makeup –

DR. GUTMANN: Future bioethics commission, one piece, one thing that you think is particularly important for the future bioethics commissions.

DR. BEAUCHAMP: I'm going to give you two, but they won't be very long, but they're quite different. The one that I would reiterate from what I said is the very great importance of people concentrating on human rights and bringing it into the arena of bioethics in a way in which it simply has not been done, and appallingly so. It really needs to be done because that's the common language that we speak internationally. And as we continue the globalization that we've seen in all sorts of areas in bioethics, I think that should be done now. It desperately needs to be done. There's another one that interests me, and I started reflecting on this from the comment that Pat made – it's also relevant to the change of context. It interests me what the place of philosophy is in these kinds of discussions that these advisory groups have. Pat said, I think you listed four areas, professions? Medicine, psychology, law – that was the National Commission.

DR. BEAUCHAMP: That's what I'm talking about on the National Commission – and I believe you mentioned philosophy. Right?

DR. KING: Yes.

DR. BEAUCHAMP: And here's what's interesting to me: There were no philosophers on the National Commission; not even one. And that's because at that time, when the National Commission was appointed, I do not think it would have been considered important to appoint a philosopher. What you had is one Protestant in religious studies and one Roman Catholic in religious studies who were in ethics. So it was thought important to appoint someone in ethics, but not in philosophy. The territory has changed. What you call the cultural context, has changed a great deal –

DR. GUTMANN: Social context.

DR. BEAUCHAMP: Yes, social context in bioethics, tremendously so from that period in the early 70's to today. And what interests me is: What is the role of the philosopher? Is a philosopher essential in the way in which a research scientist or a lawyer or whatever is –

DR. GUTMANN: Just yes or no, how would you answer that question?

DR. BEAUCHAMP: Yes, I think so. But I don't think it's all that easy to defend.

DR. GUTMANN: Okay, that's great. Jason?

DR. SCHWARTZ: So, we've talked a lot about continuity today. That's how our session ended in the morning. Questions about structure, questions about whether maybe an independent agency model like the FTC or FCC, presumably smaller, presumably without regulatory roles. But my thought would be that the next Administration should think about something as cosmetic, but perhaps as meaningful as retaining this name, right, because these groups – there's nothing about the name that prevents a future president from structuring a commission however he or she sees fit in terms of membership, in terms of mandate. And the progression of names we've seen over the last 15 years was in part to signal a difference in how one commission approaches bioethics than the other. But, again, this example of PCAST, the President's Council of Advisors on Science and Technology, is instructive, perhaps. That group's existed since 1990 under President George H.W. Bush. It's undergone many iterations. It's created by Executive Order. It changes, it evolves, but there is a continuity that even retaining the name might facilitate these kinds of discussions.

DR. GUTMANN: That's very insightful. It's very insightful. Having written a book called "Identity and Democracy." I can't tell you what little things will make people identify with one another. And that's really interesting and very simple, but very interesting. Ruth?

DR. FADEN: I'm struggling in responding to your question as to whether to land on topic or structure.

DR. GUTMANN: If you do it quick you can do both. (Laughter.)

DR. FADEN: Yes. So, on topic, and again, when it's you have a hammer you see nails, but I want to underscore that the territory for justice and human rights in health would be the territory that I would go for as well, which does not necessarily exclude science and technology, but it changes the emphasis considerably. So, in that sense, you're sort of seeing a little bit of consensus in a group that has no continuity. In terms of structure and organization I do want to land or return to the themes that have mattered so much to me on reflection, and they are accountability and resources and power. So, I think how you're structured – little things like if you have an office, where it's located; who your designated federal official is; how you're able to secure your own staff; how you elect your own staff; how you form your chair; how you determine the membership, and so on – all of these sorts of things, to use your word, to signal independence, to signal authority and also to signal that the Administration or Congress will in some sense be accountable to you even if it's in responding to your reports within a certain period of time, I think needs to be baked in if at all possible.

DR. GUTMANN: Great. Manuel?

DR. RUIZ DE CHÁVEZ: Thank you. I think that it's very important that you should keep your international presence. The cooperation, I think, is one issue which is very important, and also, to approach more the general public, the society. It's, I think, is very important. And the other is, perhaps, to address the conflict of interest in research or [in] another areas. You may know better than me.

DR. GUTMANN: Thank you. Patricia?

DR. KING: I already said what I thought. I already said that the justice and human rights stuff. I'm not going to repeat that.

DR. GUTMANN: You can do another one. We got that. That's really –

DR. KING: I'm going to say two things. I'm going to say that yes: even in future, there should be people interested in applied ethics, which is what Tom is really interested in. And any body, whatever the name, because I didn't get a chance to talk about the role they play, but they played a critical role. I – I lost my thought.

DR. GUTMANN: We'll come back to you.

DR. KING: Okay.

DR. GUTMANN: Because I know the feeling. Nandini?

DR. KUMAR: Well, coming from the developing or half-developed country, I would suggest that they should be a member who is very well conversant with the international research area because 90 percent of funding goes to the developing countries and most of it is from U.S. So, I doubt – you had a panel of this commission. If it's not affordable, at least have one or two members who are very well conversant with developing country aspects.

DR. GUTMANN: Yes, yes. And we did. Nelson, for example, is very – yeah. So Pat, you want to come back?

DR. KING: Yes, I remember it. This advice is for members of the commission and the co-chairs. On any future commission: undoubtedly, a smart, new person who's going to be chair will talk to you first, and what you say is – the only time you have a negotiated power is when somebody is asking you to do something. So, you have to educate – these things – most of what we talked about can't come afterwards so easily. So your job is to do some of this education for the next person. And I'm sure that it will either be somebody who's served on commissions or who's chaired commissions that will chair them in the future.

DR. GUTMANN: Yes. Great, great. This has been enormously helpful for us to be helpful moving forward. Paying it forward is an important part of our role. Now I'm going to ask any members of the Commission who want to ask questions or say something on this issue. One point – we'll all do one point each, and we can keep going around if we have time. Anita, we'll start with you.

DR. ALLEN: One point. Alright. So, I want to go to this notion that human rights should be an important part of bioethics discoursed on commissions because I agree, I think. I also agree that the United States has something to learn from other countries about other principles, like solidarity and the precautionary principle, that we don't routinely include in our thinking about these issues but we probably should. But I also want to voice a little skepticism. This is a question for the group here, which is: Will the human rights framework be a panacea? I think about the fact that the rights of privacy have been a part of the human rights framework since the beginning, and look at how much we've struggled nationally and internationally with trying to give some content to what it means to respect the privacy of the home, correspondence, communications, health and so forth.

DR. ALLEN: It seems right to say that we should be operating in a human rights framework and in a more international framework of principle. But, I also wonder whether that's going to be anything close to – well, I’m not sure in what way it's going to actually, on the ground, be a major step forward, given the various interpretations given these norms.

DR. BEAUCHAMP: It seems to me that you've illustrated why it's so important. It is in certain respects the common discourse, but we don't know really how to bring that discourse down to Earth. And that's why it's so important to figure that out. Right? So, of course, there's going to be a lot of disagreement and a lot of difficulty.

DR. GUTMANN: So, Tom, it's many people's discourse, including yours and mine, but it's a very contested discourse.

DR. BEAUCHAMP: Yes, but should it be? If you go to something like, say, morals –

DR. GUTMANN: You're asking the wrong person because we believe in it. And I loved your [universal] and I will stand behind it as these rights are universally applicable and they're instantiated in many documents and so on. But I just think we have to recognize it is a contested discourse. It doesn't mean it's wrong. I think it's correct.

DR. BEAUCHAMP: But if we say it's a contested discourse, what discourse that might provide a framework isn't contested? I've lived half my career hearing people tell me that a principle framework is no good. Right? Principle is a contested discourse.

DR. GUTMANN: No. We're not arguing with one another. We're in heated agreement. But Anita's pointing out that it's not going to solve the contested problems unless we figure out a way, a practical way, to get beyond just the philosophical contestation. So, I think –

DR. BEAUCHAMP: Yes.

DR. GUTMANN: You gave an example, and I don't think it was unintended so, we got to get specific. You gave an example how the IOM took on, in a very specific way, animal rights.

DR. BEAUCHAMP: Well, it didn't, though, that's the problem.

DR. GUTMANN: Well, no, but they took on a specific example. Let me just – bear with me a second. We took on human rights in a very specific way, not in the broad brush way. We took it on in the rights of children. What were the rights of children to be protected in the case of a public good, which is finding a vaccine that protected children against anthrax? But the rights involved here were the rights of children to be protected in research. And it was very contested and we broke through that contestation. At the 50,000 foot level, you can't break through it. When you get to the ground with specific examples, and you look at facts and what is acceptable in testing, you can break through that. And I think that's what a future commission would have to do. It would have to use examples. If you don't use specific examples, all the rhetoric in the world is not going to break through in any practical way. You've got to use specific examples. And I think that's what a commission would have to do.

DR. BEAUCHAMP: I completely agree with that.

DR. GUTMANN: Yes. No, I think it's important to state that there's hard work to be – after you state the human rights, you've got to get on the ground with examples of where they're really at stake. And in the cases – I'm not saying that it's going to be in that human subjects area. I think it's going to be in the area of distribution of resources and healthcare and health outcomes and things like that.

DR. BEAUCHAMP: I think the same thing's true of principles; the same thing's true of virtues. And so whatever kind of framework, you're going to have this problem.

DR. GUTMANN: I totally agree with you. Totally agree.

DR. KING: Ruth wanted to say and I wanted to point out that the Commission didn't get to the Belmont Principles until halfway through its life. Tom joined the staff at the time we started the children's report, but we operated for two years, in what I call a feeling-out process, without having any kind of framework but we had our specific examples. And so I just wanted to point out that sometimes, you use two ways. You argue the example and see where you go, and then you get to a stage where you got another example and you've figured out what is your –

DR. GUTMANN: There's actually a philosophical method called reflective equilibrium, and that's a really good way of operating. Absolutely. Terrific. Ruth, did you want to say something on this? Because I think this is really – since there's so much agreement here, how to make it practical is really important.

DR. KING: And you need a common language. I didn't say that in my report, but that's what's critical. I don't call myself an ethicist. I call myself a lawyer. But we needed the principles, ultimately, because it operated in a way to pull us together and talk to each other. In a common framework and language even though we were fiercely fighting.

DR. GUTMANN: So, this is very helpful because it did the same for us. It really did the same for us. Yes, Ruth?

DR. FADEN: So, I'm mindful that we could spend the rest of the time talking about the relationship between human rights bioethics and bioethics commissions, but maybe we should. I don't know. In response to you, Anita, I think you are in part right, depending on the level or point at which we're talking about human rights and human rights discourse. And I think maybe that's where you're going, Amy as well. I took Tom's point initially on whether a commission should take this up or not as an interesting question that – and in the field of bioethics, there's an intellectual territory. We have not taken as much theoretical account and worked as hard to make the connections between human rights theory and other aspects of bioethics. And Nita, you were framing that as well. And I think that's terribly important, and in my own work now, that's a big thrust. So that's a set piece. And a bioethics commission could be a forum for very creative thinking about bioethics theory, whatever that is, and human rights theory, whatever that is. That's separate from saying that human rights, either understood in an international law framework or understood in some other structured framework, is the right framework for an American national commission.

DR. FADEN: That to me is a very separate set of issues, and probably a big mistake. From the standpoint of the way in which an American bioethics commission can make progress and have impact, starting with human rights as your frame might be not necessarily, politically, the best way to get launched or started. Right? So the art form becomes, right – how you could in the structure of a commission going forward, if the commission were in fact given the remit or the responsibility or at least the opportunity to take on questions of justice, right, inequalities, which is a term that's more – or inequities, inequities in American health as a frame, as a big frame, a way for that commission to understand its charge as connecting considerations of inequities and inequalities with human rights, which is a natural and easy-to-do thing afterwards. Right? So, in the structure that you put together for yourself as a commission.

DR. GUTMANN: Steve? Were you –

DR. HAUSER: No. DR. GUTMANN: Okay. Christine?

DR. ALLEN: Could I just say one – 40 seconds in response?

DR. GUTMANN: Yes. Yes.

DR. ALLEN: Because I think that there's a lot of agreement here. And one thing I think that I've been trying to do in my own work is to – and I use the human rights discourse when I need to elevate particularistic concerns about inequality or privacy when people seem to not take them seriously. But “look! – human rights.” So, I took Tom's suggestion to be almost in the opposite direction: Let's start with human rights in order to figure out what we should be doing in bioethics. But I kind of tend to see it the other way around, but almost just because we haven't been, in this country, accustomed to using a human rights discourse as our starting place.

DR. GUTMANN: I have Christine on the list.

DR. GRADY: Thank you all. I'm going to change the subject, so I hope that's okay.

DR. GUTMANN: Yes.

DR. GRADY: Two things that I wanted to ask. One was, it seems like an important role for bioethics commissions is educating or making the public aware. And I didn't hear anybody talk about the public. We talked about recommendations to government and I wanted to know how you think that fits in the range of things that bioethics commissions should prioritize, educating the public or having a role in making the public aware of certain issues.

DR. GUTMANN: Could we hold the second one so we can ask you that?

DR. KING: I think all public bodies have to respond to the public. And so I think that's an important question. And I think everybody holds hearings, but I think you're going beyond that. I think trying to get public input – except if you want to talk, you can talk – to get meaningful input is very difficult and is something to have to spend a lot of time thinking about. And maybe commissions shouldn't be as responsive as we tend to be when I say, "You want to talk, we'll let you talk." We do a little bit of going out and saying, "I would like to hear from you." Perhaps that's something commissions need to do more.

DR. KING: I was intending to talk about community involvement because that's the way I think about it, and I omitted it in my discussion. But I think that if we can figure out a process, and I'm hazy about that, that would be a major step for commissions, not only education, but it is also hearing a different voice. And I think that's important, too. And I think that that's something, at least the bodies I've served on, we've listened to a lot of people. But it was less thoughtfully done or structured than I think it should be.

DR. GUTMANN: It's hard.

DR. KING: It is hard. It's very hard.

DR. FADEN: Really quickly, I want to draw a distinction between an obligation as a commission to inform public understanding of an issue that you're taking on and hoping to make a recommendation about, for example – so that's one thing – a distinction between that and what Pat, I think, was talking about, which is attempting to understand what a different constituency, stakeholders, parties, concerned with the issue think, and engaging in that respect from yet another distinction, which is our job or part of our job as a national commission is to just generally have people understand ethical issues in medicine, science, and health.

DR. FADEN: And that's a sorting-out process for a commission. It's not clear to me that all commissions have the third responsibility or need to take it on. On the other hand, you could have a commission that says, that's our job, or one of our major jobs, is to just generally elevate public understanding of ethical issues in health, medicine, and science. And that is a perfectly wonderful ambition and goal, and you could have a commission that just did that.

DR. GUTMANN: But without it being explicit, it may not be –

DR. FADEN: Right. Whereas the first, if you're taking on an issue and you're attempting to – wanting to address it, then you have some very definite obligations of the two distinct types that I mentioned.

DR. GUTMANN: Christine, you had another question?

DR. GRADY: Yes. The other one is very different, actually. I was thinking about your discussion about power, which I really appreciate because I think there is a certain power that comes with being this close to the President, for example. But I was wondering about whether you think there is more power in the model of short-term commissions that are appointed under each Administration as opposed to the FTC model or even the PCAST model, where the – maybe there's a tradeoff there in terms of how much power you have to actually get something done – splashy, in a way, versus long-term commitment. And I don't know if you think that's right or –

DR. GUTMANN: Somebody else want to respond?

DR. FADEN: Anybody?

DR. KING: Well, I think one of the values of commissions when they work has been that they are fresh.

DR. GUTMANN: Totally agree.

DR. KING: Differently constituted. Different set of issues. When Ruth raised the SEC when she was doing her typology, I went, [inaudible], because that's the way I think of administrative agencies because what they have gotten is rooted. They've got their own ways of doing business. And change is not in the vocabulary. (Laughter.)

DR. GRADY: I know. I work for the government.

DR. KING: That's right. I forgot.

DR. GUTMANN: I mean, if you want a highly regulated bioethics commission where everything, every possible thing is regulated, create a standing body along the FTC –

DR. FADEN: That was Jay's view. So, Jay had this notion – he talked about it many times – that that's what we needed in the field, that it would last forever, and his idea, of course, was that we'd be – this would be insulated. And the response that some of us had back to him, and continue in my head to have with him, is, yes. Then it just becomes – as Pat was describing – it just becomes yet another grinding whatever piece of bureaucracy. On your point, Christine, I've often thought that some of what we were able to do, we were able to do because we had a kind of arrogance that came from knowing that we were going to end in 18 months or two years max, and that was it. Right? And so, if we irritated or upset people, we irritated and upset people, because what could happen?

DR. FADEN: Now, that may be a bit of an exaggeration. But it had, at some points, that feeling about it. And when I was looking at this afterwards, I think you can have a failed commission of that sort as well, obviously. And then was it really failed? So, one of my favorites when I was looking back and looking at this was the Shafer Commission, which was set up under President Nixon. And it was in like '71 or '72. And it was in marijuana and drug addiction. And one of the things about – when you set up a commission like that, you can't control what's going to happen. President Nixon couldn't control it. At a certain point, the Administration loses control.

DR. FADEN: And that commission recommended the decriminalization of marijuana in 1972. Right? This is under a Nixon Administration. So, obviously, Nixon hated it. The Administration hated it. They didn't want to see it. It was an embarrassment. They dismissed it. It's taken 'X' number of years. You could say that was a failed commission. It's extraordinary that that was their recommendation. At the time, you would say it was failed. Nobody paid any attention. How many people now go back and look who work in this area at the Shafer Commission? I don't know. But it's an example of – had they been a commission that went on and on and on, I'm not sure they would have reached that recommendation. Maybe that was good, maybe that was bad.

DR. GUTMANN: Jim?

DR. WAGNER: I'm done. But since we got some time, I didn't want to leave unchallenged, or maybe un-clarified, a statement that everybody seems uncomfortable with. And Pat, you made it initially in the earlier panel and then it was echoed here that future commissions might – I think the language you used is return to medicine and health and not so much the research dimension. And the reason I'd like a clarification on that is it seems to me there is a need in the research. So I could understand that if what you're saying is we should expand what we do to include – what future commissions do to include this, first because I think there is still, and there will continue to be needs in the research side. We see technology roll out that's ahead of our ethical thinking. We haven't fully thought through what CRISPR might mean.

DR. WAGNER: And then secondly, it seems to me that some of the very solutions, possible solutions, to health disparity may be technology-based. And in fact, to the extent that we can infuse research with ethical purpose, not just ethical regulation but ethical purpose, including the purpose for addressing such issues as health disparity, I would want research to stay on the agenda of future committees.

DR. KING: I have nothing against research and technological developments. I want to be clear about that. It's just that when I look over the history of a lot of the commissions and bodies, and it started with the National Commission, that has been our focus. And the issues that we look at, research, were always intended – the basic scientific research, not these big – we're doing something different now, mitochondrial DNA. We started with just basic research, which needed to be straightened out, quite frankly. It was in transition. But the other side of – and I think of research as improving health and well-being.

DR. KING: The other side of the health and well-being has to do – and it has technology, too – has to do with people's health status, people's healthcare. And to me, my circle includes research and the other. And from where I look, we've spent – with the exception of the commission of which Alex Capron was the Executive Director – we've spent a lot of time on the research side. But I see research as a way of getting to an end. And we have missed, I think, given that that commission was in the 1980s – we haven't spent a lot of time. I'm not talking about healthcare legislation. I'm not even talking about regulation. I'm talking about nobody has really looked at that side and highlighted some of the issues in an era in which – and I deliberately didn't choose aging because I have to think about that too much –

(Laughter.)

DR. KING: – but in an era where our delivery systems are changing rapidly, where we have technological advances that go to the care side as well, where there's a big need for education. We have sort of ignored it. That's basically what I'm saying.

DR. WAGNER: Yes. So, your call is to include it. It's not necessarily to shift, but rather to expand.

DR. KING: But when I said shift, we need a shift for a while. What I am saying is we've spent all our time on research. It's the glamorous stuff. The hard stuff is looking at who benefits and how, on the other side. I include it all. But I do think we've given a disproportional amount of attention to the research side.

DR. BEAUCHAMP: Can I make a small footnote to that? Although I think it's an important subject. The National Commission took up the question, should there be regulation of medicine, not just regulation of research? And it debated it at some length, and I think it was only in one session, but at some length, and it came to the conclusion: of course, clinical medicine should be regulated. You've got as many risks and so on there as you do in research. But, you can't do that. First of all, it's beyond our remit; nobody gave us a remit to consider that. And secondly, it's a political disaster to even take up the issue. But now it's a real issue that needs to be taken up. Now, you want to get rid of the word "regulation" and replace it with a word like "oversight" or something like that. Well, what systems of oversight need to be introduced to govern, so to speak, or bring under control, certain really negative features about risks in clinical medicine? And we've never had that discussion in a bioethics commission.

DR. GUTMANN: Nita?

DR. FARAHANY: I want to pivot us a tiny bit to something we had talked about earlier but that I would love to hear your perspective and reflection on. So, assume a future commission took on one of these broader, more systemic issues. One of the things that Amy mentioned has been a hallmark of this Commission is consensus reports. And I think there is great virtue to consensus reports in that you model what consensus would actually look like in politically divisive times, and at a time when, if we can't come to an agreement, how could we expect anybody else to? And yet the commissions also serve a different role, which is a public discourse role. And to the extent that they have lasting impact on the conversation and discourse of fields going forward, many of these are controversial topics on which even a commission who's worked together for six years won't agree, or if they do agree, it'll be a watered-down version of what more articulated differences might be.

DR. FARAHANY: And so, given that you had different experiences on your own respective commissions and organizations as to whether or not there were consensus reports or dissents or separate member statements that were written in order to elaborate, I'm curious as to what your recommendation would be for a future commission in thinking about how to balance those two important functions between being able to reach consensus in order to influence policy and make real recommendations that have the power to influence versus being able to have a really fulsome public discourse around an issue.

DR. GUTMANN: And please take into account the context we're living in and will continue to live in, which is social media. A commission like this will not – our deliberations are a model of civility, but there's not a chance that how we deliberate is going to affect, significantly affect, the way people who want to be in the public eye and carry big constituencies with them will deliberate. You just have to put a reality principle into this.

DR. KING: I have a favorite story, and that is, I actually was co-chair of one of these deliberating bodies. And I tell everybody, it's a poor chair who has to dissent from her own committee's report. (Laughter.)

DR. KING: Which I did. So, I'm going to say something – and so I thought about it a lot, your question. I think when you move – consensus gives impact, and everybody has to understand that. So that's what you work on. But I think it's a crazy world, that if a person feels strongly enough after you've worked hard that you try to tell them not to have a dissenting report, I think there's something to be learned, often in creating a consensus, as you point out. You lose valuable things because you're really – everybody has a goal. One of the ways of conveying the richness of a disagreement, I believe, is the capacity to dissent. And if everybody understands the up side and the down side, I'm all with it myself.

DR. GUTMANN: And I think it's important for us to say if anybody feels strongly enough and has reason to feel strongly enough to have to issue a dissent, that should be the case. This group is in consensus on that as well, that we would never block a dissent. But we shouldn't, in the context we're living in, glorify what dissent –

DR. KING: What consensus means.

DR. GUTMANN: Yes. Right. We shouldn't underestimate what you need to move forward, but also that it's important to be able to dissent. Absolutely.

DR. KING: I don't know if that answers her question.

DR. GUTMANN: Well, could you say? I'd be interested, because I may be the only – am I the only one? I don't know. You were the head of a group that you had to dissent from? DR. KING: The embryo research panel.

DR. GUTMANN: Could you say why, I mean, what happened? I think it's – would you be willing? I think it's important.

DR. KING: What happened was, as you can imagine, this was pre-stem cells but, the embryo research, we all knew stem cells was coming. And we put together a report that I thought was too broad in the sense that we were trying to anticipate everything that was coming, and stem cells being the big one that was coming. In the face of real disagreement about pro-choice/pro-life, a one step at a time – I'm an incrementalist. So, it's the report that I decided that I had to dissent from because I thought we hadn't considered and deliberated about issues in detail. Mostly, it was about the creation of life. We were talking about embryos. And I just thought I had to say it, and I thought I could say it as a person who was pro-choice.

DR. KING: So, I did. And so President Clinton disavowed the report two days later – not because of my dissent, because of his own political issues. But we just – and maybe that's a lesson about these groups sometimes, and that you have to be strategic in deciding what you can get this round and have an impact on this round and not reach for the sky. And I can say this in public because the members of that group have all gotten together since then, and we all talk, and we all say we learned a lesson.

DR. GUTMANN: So, because we have a hard stop, I just want to conclude this meeting by thanking you for being so thoughtful and open and helpful to us, and also say that it really is an honor to have, across the generations of commissions, enough commitment and identification to be able to share together. And we feel that we have a very strong responsibility, speaking of responsibility. We had a very broad remit, very broad charge. And we took some very hot-button issues and deliberated on them and heard from the widest range of people. We also do feel a kind of obligation and responsibility to pay it forward with education, and we have educational materials and also a report on how you can deliberate in this social context in an effective way. And we feel very beholden to previous bodies with different names, although I think it's a great idea to have not a standing body, but have a name that perpetuates. I think we could call ourselves Bioethics Commissions across – National Presidential, in our case, Bioethics Commissions. But I just want to thank you for being so, so thoughtful and insightful. And I want to in particular thank our two international guests and members for sharing with us their experiences. So let's all – thank you. (Applause)

DR. GUTMANN: I do want to remind everybody that our website, bioethics.gov, is alive, and you can put any comments on it. And we are going to work in a way to make sure there is an easy way of accessing. My fantasy – it's not a science fiction fantasy, is to have an app which anyone can go to. But whatever it is, we're going to make sure there are ways of accessing this over time. And I also just want to take the opportunity of thanking our wonderful Commission members for your service. So, thank you very, very much. And I want to ask Jim Wagner, our Vice Chair, to have the final world, but thank everybody in the audience and our wonderful as well.

DR. WAGNER: Actually, no final word to add except again, thanks to all of our guests. Thanks to the Commissioners. Amy, thanks to you for your leadership. And with that, I assume we stand adjourned.

DR. GUTMANN: Safe travels, everyone. (Whereupon, at 2:56 p.m., the Commission was adjourned.) * * * * *

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