Friday, September 9, 2005

Session 5: Taking Stock; Looking Back, Looking Ahead


Council Discussion

CHAIRMAN KASS: Good morning.  Welcome, Members of the Public, Council Members.  Thank you very much, once again, for last evening.  It's my great pleasure to start this session of Council by welcoming as our guest for today and soon to be new colleague and Chairman of this Council, Dr. Edmund Pellegrino, who sits to my left.  Dr. Pellegrino, if he's not already known to you all, should be.  He has been a physician for more than 50 years, still practicing medicine, where he's Professor of Medicine Emeritus at Georgetown University School of Medicine and makes rounds on the wards.

November, I think, is the next tour of duty.  He has been one of the country's leading thinkers and writers on the philosophy of medicine, the doctor/patient relationship, the founder of — co-founder of the Journal of Philosophy in Medicine and one of the clear thinkers and wise guides in the area of ethics and medicine.

He's had administrative positions with organizations, I'm sure, larger than the chairmanship of the President's Council on Bioethics, the last — well, not the last, one of them being President of Catholic University, was Vice President of Yale New Haven Hospital, ran the hospital and I can't tell you how delighted I am that Ed will be replacing me in the Chair. And to quell any gossip from anybody who scribbles, I will be remaining as a member of the Council and will be delighted to continue working with all of you and under Ed's leadership and guidance. 

So please join me in expressing our warm greetings to our new colleague.

(Applause)

CHAIRMAN KASS: I've asked Ed to sit in this morning because the two topics for today are of a special interest for us going forward.  The first session is entitled "Taking Stock: Looking Back and Looking Ahead," in which we will have a chance to reflect on what we've done together these past four years and to offer some suggestions and thoughts about what we might do, suggestions we present amongst ourselves but also for Ed's consideration as he contemplates the new directions.

And the second session will be on the "Medical Vocation Then and Now," a subject not only dear to the new Chairman's heart but absolutely central to many of the things that we've been talking about and will talk about in the future.  I'll introduce that session when we go forward.  I think we should divide this session really into two parts.  It's very rare for any group of people, except in therapy sessions, of group therapy sessions, to actually sit together and reflect openly and in this case, in public, on the work that we've done and to try to think hard about what it means to try to do public bioethics today with the kinds of issues that we face, not primarily to settle scores or to deal in anything petty, but to see if we've somehow learned something that could be put to use in making the work better as this Council goes forward.

And then second, I think we should do as we've done on previous occasions, talk about possible topics of importance that this Council might continue in its third term.  Some of those things surfaced yesterday and I thought you might like to bring them back.  This is sort of strange, but I would like to ask — so as to save time, you've been given as a background paper, the talk that I gave a year ago and is now going to be out in the Kennedy Institute of Ethics Journal within a couple of weeks.   So as not to waste your time but because I would like to get certain things in that article in the public record, could I ask unanimous consent to put into the minutes of this meeting as if read a few of those general reflections at the end so that people who are not here but who know us only through the transcript of the meeting and will not see that paper, can at least have one man's perceptions of these matters.  Is that all right?  Good.

Then let me introduce the discussion today, the more reflective part of the discussion with these comments.  This Council has been guided really by two inter-related purposes.  The first purpose has been to pursue what we've been calling a richer bioethics.  That is to say, to consider not just the technologies or the way in which they give rise to questions familiar to either clinical medical ethics or to general sort of common concerns of a liberal democratic society, but also to see how these things which impinge upon our humanity, in fact, touch our personal aspirations, our human longings, our duties, our — the way we actually live life every day and in deep and serious ways. 

We've tried to think about what it means to suffer, what it means to welcome a child into the world, what it means to perform with excellence, what it means to respect life, what it means to age well and care always, and almost everything we've done has been informed by attention to these anthropological and not merely ethical matters.  And I don't think that this Council would have satisfied itself with the view that all that bioethics can say is that everyone should make informed choices for themselves.  As a public bioethics body respecting, to be sure, the pluralisms of the society, we've been asked to offer as the charge this Council had, the results of serious inquiry into the human and moral significance of these advances and that we've tried to do. And speaking for myself, I think that's something that we should be very proud of.

The second purpose informed by the first, but not always easily or comfortably related to it is to try to be useful to those who are charged with making public policy in the age of biomedical science, on issues ranging from stem cells and cloning to the regulation of biotechnologies, to the care of the elderly, the demented and dying. 

We've tried to take seriously our mandate not just to think but also to guide, and not just to think about ethics but to think also about self-government on issues that are both ethically profound and scientifically complex.  It's, I think, not for us to judge our achievements or failures in this area but it remains for me a challenge and a puzzling question — what's the relation between this search for a richer bioethics on the one hand and the desire to be genuinely useful in the concrete decisions that public policy makers face, and in particular the topic of regulation.  

We've tried our hand at this.  We are quite concerned that we live in a society which is largely unregulated when it comes to all of these revolutionary areas of biotechnology.  And we know that there are obstacles to going forward here, but it seems one of the things that is very much worth pondering as we go forward, can we hold these two tasks together and could we do either or both of them better?

That's to prime the pump.  I really — never mind that there are scribes possibly in attendance.  I think we should have — this is not a time to pat ourselves on the back.  It's a time to try to figure out what have we learned from trying to do this work together and what could we do in order to do these things better? 

MALE PARTICIPANT:  This is the first time in history you've completely silenced the Council.

CHAIRMAN KASS: No, no.  I knew it was a good question.  You ask a good question in class, nobody speaks.  Diana, was that an offer?

PROF. SCHAUB:  I don't know if it addresses what you've asked us to address but I think we ought to think about whether we have done enough to reach the public.  I mean, I think the Council has done an incredible job on the score of a richer bioethics, but has the public been sufficiently enriched by what we have done?  I mean, have we gotten it out to them?  So I mean, I just wonder if there are small things that — I mean, that we could do more in the way of meeting that charge of educating the public and informing the public. 

I mean, the books are out there but people are not always readers.  So, you know, ask ourselves, you know, are these books getting into the hands of the people that we want them to get to and for those who are disinclined to read, are there other things that the Council could be doing?  I mean, I know that individuals do a lot of public speaking to, you know, university crowds and you know, other kinds of fora, but people do that as individuals.  And the things that I've done like — done in that line to alumni groups and, you know, college audiences, there's a great deal of interest and there is a great deal of ignorance. 

So I mean, I wonder whether the Council could do something like, you know, take this show on the road, you know, have a — these are public meetings.  Stage the public meeting not at a hotel in Washington, D.C. but at a major university or I don't know, I mean, it would just — you know, trying to figure out are there other things that we could be doing or at the risk of being too political, part of the charge is to inform policy makers and legislatures.  Are there acceptable ways to run information programs on the books that we have — books that we have written for you know, staffers, congressional staffers?

CHAIRMAN KASS: Thank you.  This thought has — I'm not going to editorialize after every comment but on this particular point, it's been a concern of mine from the beginning and we've been so preoccupied in a way with doing the reports that there hasn't been a lot of time and energy for these things, but to send even staff out with the reports to college campuses and do things like that was one thing that we considered.  I'd also considered putting together a small group of journalists and have seminars with them on the reports.  I mean, just make them read the things instead of the last page, and have regular seminars, but just there wasn't time and energy enough to do that given these other things. But a lot of what we — a lot of what we do insofar as it's not — well, two things, three things.  First of all, if one is speaking about the policy makers directly, Charles Krauthammer told me when I took this job, "In Washington if you want to educate anybody, you have to tell them what to do, so a report with no recommendations is politely ignored."

I mean, people look and say, "Is there anything here I really have to pay attention to?  I'll read it when I have time", and these people have lots on their plate.  So — but then the people who really do the educating are a couple of dozen journalists for, you know, medical journals, Science, Nature, the general press, our fine observer, Mr. Saletan here, who is a very astute reader of these things, and if one could sit down with this group of people and get them to go past the things which very often make up the stories about these matters to get them to deepen the accounts that they give, there would be a way in which one could multiply the educational effect through the people who actually do a lot of the public education for worse and sometimes for better.  And that's, I think, something worth thinking about.

There was a third thing, but the gray cells are gone, so let it be.  Please, Robby?

PROF. GEORGE:  Leon, I think the largely unwritten, even unremarked, story of the Council was there right at the beginning and it's the remarkable diversity of points of view on the Council.  The President's willingness to appoint to the Council not only people who agree with his fundamental moral outlook on the questions before us, but also some who don't and some who deviate very, very sharply indeed from the President's own perspective. 

When it became clear to me that that's the kind of Council we would be, I wondered what the result would be in respect to the reports that we would be able to put out and what the value of the reports would be.  Since most, perhaps all previous bioethics councils have had more uniformity of viewpoint on them, they were able to write reports that took a point of view and made an argument and advanced that argument quite vigorously.  Our reports have not been shaped in that way precisely because of the diversity of points of view on a number of occasions.  So I wondered whether they would be valuable.  Well, my conclusion, now that we have a good deal of experience with them is that, in fact, it is very valuable to lay before the American public and particularly before people who are genuinely interested in these issues, the best arguments to be made on the competing sides of the question and the best available information as to what the plain facts of the matter are.

In our initial report on cloning, although we were very badly divided as a Council, we were, I think, able both to lay before the public the strongest arguments that were available on the competing sides of the question and also to clarify the underlying facts about which there was floating around out there a lot of misinformation.  We were also, and I think a very, very important contribution neglected, unremarked, able to clarify the language and to be clear on what we were talking about at a time when the need for such clarification of language was very, very important.  I hope that we will continue and I am confident that under Dr. Pellegrino's distinguished leadership, we will be able to continue to produce work of this quality and accomplish what we have been able to accomplish with the reports that we have done this far. And when the day comes when this Council wraps up its work and perhaps, a new President of whatever party is elected and thinks about how to constitute such a Council if he or she wishes to have a bioethics council and I suspect that bioethic councils will continue in our future, I hope that a lesson can be drawn from the diversity that we've had on this Council and the valuable work that's come out of the diversity on the Council.

CHAIRMAN KASS: Thank you.  Frank Fukuyama.

PROF. FUKUYAMA:  Well, in the spirit of Dan Foster not wanting to grow extra muscles by patting ourselves on the back, I guess I do want to register my own, you know, one area of disappointment in what the Council has done.  I accepted Leon's invitation to become a member of the Council, with really one purpose in mind, because I wanted it to address very forthrightly the regulation issue. And my hope at the beginning of the Council had been that this might develop a little bit like the Warnock Commission in Britain in the 1980s which, you know, studied the upcoming, you know, revolution in biotechnology and then recommended creation of the agency that became the HFEA, the Human Fertilization and Embryology Authority in the UK. 

And I had hoped that our work might be able to lead in that direction.  Now, I think it became clear as we started very seriously delving into the regulation issue, that we would, you know, touch on the margins of that but I think that politically, I mean, it's not the fault of this Council.  I think it's just American political culture.  There's a kind of very deeply rooted anti-regulatory bias on the part of both the left and the right in this country for different reasons, you know... to produce the kind of situation that we have. And I think on the Council, the reason we couldn't go forward was a number of people, Gil and Alfonso, you know, raised this question, well, if you don't know actually what you're going to regulate or what the regulators are going to do and give them, you know, those instructions substantively, how can you say you can build the authority.

Now, I actually think we could have gotten past that because the HFEA in Britain regulates and permits stem cell research and research cloning.  The Assisted Reproductive Agency of Canada, this recently established body, prohibits research cloning and very strictly regulates stem cell research and they have almost the identical institutional structure.  And I think it would have been possible, actually, to recommend the creation of an agency with the appropriate powers and domain and specifications and actually then kick the ball down the road to the political authorities to decide, you know, whether it looks more like the Canadian agency or more like the British agency in terms of whether it either permits or restricts research cloning.  But, you know, it was a very difficult hurdle to get over.  We did, I think a very respectable job in the "Reproduction and Responsibility" report where we actually, as a way of trying to get past the cloning deadlock in Congress — I mean, in fact, we made multiple efforts to suggest to the political authorities concrete ways of, you know, breaking through the current political logjam so there would at least be some effort on the legislative front to address issues that we all agreed, you know, needed to be addressed.

I believe, however, that this is still an area that we did not, you know, push the ball all the way up the hill.  That was one of the reasons that I got independent funding for the study that I presented to the Council last December, where I just went ahead and on my own I kind of laid out what I thought this kind of an agency ought to look like and I think that's still on the national agenda. 

Now, being politically realistic, I think that what's going to happen is that, you know, various people will make suggestions along these lines and then at some point, some, you know, doctor is going to try to clone a human being and it's going to lead to some deformed, you know, horrible outcome and then people are going to look and say, "Well, you mean to say that this was legal in this country, that this isn't regulated?", and you know, people saying, "Yes".  Well, in fact, that is the case, that we don't have any rules whatsoever that prohibit this sort of thing.

And just as in — you know, as it took the Enron meltdown to discover that we actually did have very good, you know, accounting standards in this country, I think then people will be willing to politically take up this issue in a more serious way.  But I do believe that this still remains on — you know, on the agenda for not just this Council but future ones to think, you know, as Leon was saying, more concretely about not just legislative acts, but institutions that will, you know, help guide us and kind of structure political decision making in this area as we go on into the future. 

CHAIRMAN KASS: Thank you.  I would — I guess while people are collecting their thoughts, I would underscore what Frank has said but give, maybe one additional comment.  It — it's been one of my frustrations here, Frank, as well, though I saw very early on, I think it might have been Gil, Gil said he'd be all in favor of a regulatory body if we could — if he could identify the goods in the name of which the regulatory body would regulate and also appoint its members, otherwise he wasn't sure that one wasn't going to be as it were, giving carte blanche to something about whose moral rightness he had grave doubts, and it's too bad, in a way.  It was inevitable but too bad that we tackled the regulation question in the absence of any kind of — maybe we should just call it to begin with "oversight monitoring," which we don't even have other than on safety and efficacy criteria. 

It's too bad that we tried to do that around the series of innovations and technologies where the embryo stood in the center of the road.  And the embryo is really like Solomon's baby, we're not going to split the difference on that one.  Could you do something to think about regulation with the off-label uses of drugs? Much harder because those uses are decentralized.  You don't have any — it's much less visible and much harder to get ahold of.  If one were really interested not in the particular area that had some kind of oversight and regulation, but the principle that governance here means not periodically trying to ban something, but to try to separate the better and worse uses of these innovations and that it ought to be done by public means and not by accident, then it seems to me the real task, recognizing the political difficulty until there might be such a biotechnical Chernobyl, would be to try to find some area where one could think about this without having such a hugely divided view as to what the — what the morally right thing is. 

And I have to confess I haven't really thought this through at the bottom, but it's not obvious to me.  It was partly an accident of what we started on and of the cloning report that we turn to this intersection of genetic knowledge, reproductive technologies and embryo research as the area to try to do this, but it became very clear after a couple of meetings that at least in this body and this body being somewhat representative of the larger community, that intractable question was going to at least for the time being stand in the way of getting some kind of an agreement.

So it is a disappointment of mine.  It's a disappointment that comes also with recognizing the reasons why we have this in addition to the American hostility to regulation, the fact that the scientists  and the biotech people don't want government mucking about at all, but I do think that it's worth all of our attention to see if we could find some other area appropriate to things that we're doing where it might be more — where we might be more successful in suggesting some kind of oversight and monitoring body and, perhaps, even some regulation.   Gil?

PROF. MEILAENDER:  One thing I want to note, this is not the main point I wanted to make but in relation to Diana's comment is, I had several times suggested that we should meet in other cities.  It's logistically sort of difficult and I think that was one of the discouraging factors, but I thought it would be interesting to do that. 

But the main thing I want to say may seem perverse to Frank, for instance, maybe even to our distinguished Chairman, but for me, the — and I'm even willing to grant, I guess, before I say it, that this may be to some degree a matter of temperament, I guess, though it is in some ways also for me, anyway, a matter, you know, having taught for 30 years, the day before I left for here, I got an e-mail from a student I taught has to be 20 maybe 25 years ago, I had to pull out my file of old grade sheets to figure out who she was, but who had read some stuff of mine and was helped by it recently and wrote me.

If you do — if you teach this kind of stuff, your clientele comes and goes and if you'll pardon the theological formulation, you have to live by faith and not by sight.  It doesn't pay too often to ask whether you're accomplishing anything.  You just sort of have to do it and hope that somebody out there is benefiting from it.  And maybe over the decades this has had an effect on me, but I very seldom ask what I'm accomplishing.  I don't like to ask that question.  I prefer just to kind of let it go and see what happens.  And for me the most satisfying moments have been when we haven't worried about whether we're going actually to accomplish something in a policy sort of sense but have simply tried to sort through a question and say something about it.

Now, it may be true, Leon quotes Charles.  It may be true that that falls into a black hole.  I don't know about that but on the other hand, in the moments when we have attempted to shape policy, no one could claim we've been extraordinarily successful in doing so.  So I think that actually the best work we've done has been in our attempts just to sort through hard issues and not worry too much about the implications.  The moments when we've tried to come down to a point have several times been excruciating but also, I don't know that they've gotten us very far.  So I don't think it's a bad thing that this should be, as Robby said, a very diverse body, that we should not necessarily be able to come to a point that it should be somebody else's responsibility to try to accomplish something, and that we should just think and talk and argue about questions.  That doesn't seem to me to be bad and I understand that it may seem perverse.

The one additional thing that I'd add is that — and this is the place where I do have a little different tact from our Chairman's.  See, I don't think of the — what I grant are the unresolvable life questions or whatever you want to call them, as sort of getting in the way of making progress on other things.  I just think they're basic.  You know, if you're going to talk about bioethics, sooner or later you're going to talk about whose good counts among us and if the price of recognizing that those questions are basic is to be a little — to accomplish a little less, that's okay with me, you know.  I — that's sort of the story of life as far as I'm concerned. 

So I wouldn't want to — I wouldn't want to, as it were, bracket those basic questions just in order to try to get somewhere because I think usually you don't know where you're getting actually and you only find out 30 years later anyway and it's therefore, a bad idea to make that your chief priority and I think we — a lot of times we haven't and that's good and those are the best times as far as I'm concerned. 

CHAIRMAN KASS: Alfonso.

DR. GÓMEZ-LOBO:  In many ways, I feel in a similar manner as Gil does.  Accomplishments are something to be taken into account but not too seriously.  But, however, I would like to, perhaps rehearse some of my differences with Frank on these matters.  Even if one is not out there to be successful, still I think the question of regulation is important and I think that, of course, the political community has to find regulations for the protection of some of its most important values.  I wouldn't doubt that for a second.

And my real problem with the British Human Fertility and Embryology Authority is just how it works.  That's where my main problems are.  First, I have a very, very poor opinion of the Warnock Report itself.  I was astonished when I first read it how shallow it is philosophically.  It puts forward a very simple utilitarian argument then a moral sentiments argument and leaves it at that and then comes down on the 14 days without further ado.  I mean, it's really astonishing how little reflection there is.  For instance, by comparison, and I'm afraid I'm patting ourselves on the back again, our reports are much more careful in the — in laying the foundations for whichever way the regulation may go.  It's just incredible that the British Parliament should have taken that report as is, as basic, and passed the bill on those terms.

But again, since we are dealing with such a fundamental value for our society for the political community, value of life, I just don't see how a committee of, I don't know how many members the British committee had, but 20, 30 people, are making such important and drastic decisions on their own authority.  Now, there is guidance and there's the possibility of guidance as Frank has reminded us of the Canadian case, but if I could have my way, my preference would be that there be regulation at a much more fundamental level so that it would not be a small group of people that were making — would be making these decisions.

And if we could move in that direction, that would be just wonderful in the second stage, but again, it's not going to be possible without a much deeper study and discussion of the grounding issues here. Thank you.

CHAIRMAN KASS: Rebecca.

PROF. DRESSER:  First I want to say, unsurprisingly, how beautifully written this article is and I personally enjoyed very much hearing that speech as well as reading your response finally, sort of how you see our work, and it's a relief for you to speak out and I appreciated that.

In terms of topics, I'll throw out a couple that we have talked about previously.  I'm not necessarily advocating on their behalf but just to get some topics out.  I think yesterday and previously we have discussed trying to do something on the health care system.  What exactly that would be, how we could provide any wisdom given our composition without health policy people and so forth, is — those are questions but that's one possible topic. 

The other we discussed in the past was commodification of the human body and the role of the private sector.  I think yesterday we heard a lot about how the private sector is influencing the treatment and the options for long-term care of older people.  You have many lobbyists promoting the cutting edge therapies and the drugs and so forth.  And those are the things that tend to get reimbursed and supported.  You don't have the lobbyists supporting plain old personal human contact and social works kinds of things and so those are not as available in the system.

So the role of the private sector is underlying most of the topics we've considered and so maybe it would be interesting to do a topic like commodification of the human body that would bring it in a little bit more directly.

CHAIRMAN KASS: Thank you.  And let me use Rebecca's turn to possible topics to say that both questions are on the table and we shouldn't let this session go by without really offering eager thoughts and collectively trying to formulate some suggestions of things that might go forward.  Paul and then Mary Ann.

DR. McHUGH:  Well, I wanted to follow up  with what Rebecca said but I also want to follow up on what Mary Ann also said and was very persuasive about yesterday.  I think there are two things that I would like to see the Council move towards in relationship to discussing matters of American life and ultimately following the Krauthammer rule in telling people maybe what they ought to do.  We've spent time talking about the aged.  Now I think is the time to talk about children and the family.

It is at last becoming clear that the forms of families that have been developed, especially divorce and the like, are very harmful to children's psychological development and the casual way that we approach that on regulatory and various other ways has been a scandal to our country as is now clear to all psychiatrists who care for the products of those families.  But there are many other things about the  child's position and its vulnerability towards — not simply towards its life, although that's at stake too, but very much in relationship to its flowering and flourishing as a human being and what constitutes the kind of structure that if it can't be provided by the family, we should be talking about how it could be provided and what kinds of things come natural to a family and what kinds of things, therefore, have to be structured elsewhere.

In this sense, I'm reminded again, as a psychiatrist, is what happened when we did the deinstitutionalization of the mentally ill.  For awhile, we simply turned them from the back wards into the back alley of our cities until coherent community psychiatry people like the leader at Hopkins, William Breakey, began to talk about how we needed to reconstruct in the community the kinds of resources that were easily available in the institutions — the occupational therapy, the vocational therapy, the various kinds of services that were previously available and did great good for those people in the message of a less confined life for them.  So that's one issue that I think is right before us and might well, as I say, for the child development policies that even the discussion of them and even the considerations of the data that are now available would be extremely helpful to developing policies.

The next thing related to the new director is a point that we've made several times before, that this is a Council on bioethics and maybe the time has come at some point to talk about whether the bioethics move has met its promise.  Some — the claim was that with the new technologies and the new availabilities, that we really needed people who had fought seriously about these matters in order to help us doctors to deal with the issues in the front.  Well, that continues to be a — what we're seeing a lot, yesterday, and empirical question at least and very much a question that I struggle with and I hope our Council would.

Our coming Chairman has done wonderful work in my opinion in discussing these matters and challenging what sometimes becomes the lingo of bioethics, these autonomy words, beneficence words and talk to us more coherently about the sort of virtues that spring up from a flowering opportunity to care for people and the appeal that people have to you when they come asking you for your expertise.  So at some point, I would like to hear the various champions of bioethics come and tell me and us and therefore, the American people, that they've advanced us from what were the ethical principles that were taught to me in the '50s before bioethics was even heard of.

CHAIRMAN KASS: Mary Ann.

PROF. GLENDON: Well, Dan, I don't know exactly where the deltoid is, but I'm sure wherever mine is, it needs some exercise.  I do want to amplify a little bit the theme that Robby sounded about the diversity of this Council.  Robby mentioned the diversity of viewpoint but there are other kinds of diversity that have posed a real challenge for us and I think one of the great achievements of this Council has been to overcome them. 

How difficult it has been for people to communicate across disciplinary boundaries. That's something, I think, one tends to take for granted that you can put a group of scientists and humanists around a table and since we're all English speakers, we will be able to get on with the business.  I would say it took us even a year or two to move across the boundaries, some of us with great enthusiasm.

I felt about the four years on this Council it's like going to graduate school again.  It's been wonderful.  It's been a great education.  And there's another kind of diversity that is equally challenging and that's the one that comes out in the exchange between Gil and Frank.  Some of us are more practice-oriented.  We're looking for concrete recommendations for conclusions, solutions and some of us say, "Oh, oh, be careful.  You don't want to rush to the recommendations and conclusions unless you're sure you have really understood these very complex problems". 

And I think the way we have dealt with that — and our current report on aging is a beautiful  example of how we have kept that tension alive, that theory and practice are, indeed, the two blades of the scissors and you cannot make a pleasing construction without using both of them.  And it's always going to be a tension, but it's one that I would hope the Council will keep alive, that we can't really go off in one direction or another. 

And finally, Paul has said it already, better than I could but I would urge the Council in the future to try to adopt a capacious understanding of bioethics along the lines that Rebecca has often recommended and in the case of attention to the problems of demographic change in our society, keeping in mind that children as well as the elderly, are at risk of being marginalized and that questions about priorities and research and allocation of resources in our country are questions that have a strong ethical dimension.

CHAIRMAN KASS: Peter.

PROF. LAWLER: Let me just comment on some of the ideas put forward.  First, I want to agree with Alfonso and Gil that we professors of abstract subjects really can't think in terms of accomplishments very well.  By coincidence, one of our new faculty members asked me, you know, a relatively old professor, "How do you know you have accomplished anything"?  And then my dean asked me, "How can you assess what you've accomplished"?  And these things make me feel guilty for the rest of the day but then occasionally, there will be a moment like Gil had where you know, well, maybe I have accomplished something.  In terms of taking on the profession of bioethics, in my opinion, all our reports take on the profession of bioethics. 

The question would be, should we continue our indirect assault or go to a direct assault?  A direct assault might result in many casualties and I've been very relieved in attending these sessions of this Council that we've never had a card-carrying professor of bioethics testify.  And —

CHAIRMAN KASS: That's really not true.  It's repeated but it's just not true and allow me to correct that. 

PROF. LAWLER: Okay, well, it depends what you mean by card-carrying.  I don't think Mr. Caplan has testified.  But I'm saying the autonomy model of  bioethics is taken on so forcefully and beautifully in the report that just came out that I don't need — I don't think we need to name names and go after people in particular.  We'll just continue what we're doing, thematically without showing that the dominant academic approach to this is rather bankrupt.  We can show that by example without saying that straight out.  I could be wrong on this.

PAUL MCHUGH:  Psychiatrists mainly.

PROF. LAWLER: And many other members disagree with me on that, but the — and I think we're on the cutting edge of this and they are the ones who are washed up actually is my true opinion.  An issue that —

CHAIRMAN KASS: You're now going to come to the provocative comments.

PROF. LAWLER: No, I could say more, but I mean, we need to be constructive now.  The two issues that were brought up yesterday that caused me to despair part of the evening.  One was reform of the health care system.  Our report says that should be directed to the new Commission and I think with good reason.  We don't have the technological expertise and yesterday we heard that these days, which seem like critical days, will be the good old days in the future.  Everyone is dissatisfied with the present system.  No one knows what to do.  Maybe this is not our task.  Maybe this requires more technical expertise than we have. 

In terms of the demographic changes, the importance of those is presupposed in the existing report, the report that's going to come out at the end of the month, but certainly more study there and what's the world going to be like with many fewer children, I would be in favor of that.  But the issue yesterday that was brought up as a platitude many times is we have to value caregiving more as kind of a content imperative.  We have to value caregiving more but no one explained how we would actually do that because caregiving, like everything else, has been commodified. 

It's a sustenance kind of thing.  How do we value caregiving more?  So I would actually like to see us study that as a separate issue.  You can't just say you have to give these people more value, you have to have some plan for giving people more value in an individualistic autonomous world where people who just care are devalued more and more.  And so in general, the general issue of commodification seems to me to be huge.  And so maybe we ought to focus on one particular area where commodification is a problem.  And I might think that area might be the valuing of caregiving. 

CHAIRMAN KASS: Thank you.  Diana.

PROF. SCHAUB:  Yeah, I just wanted to make a quick response to that anti-accomplishment crowd.  That was a beautiful phrase, Gil, about living by faith and not by sight, and I'm —

PROF. MEILAENDER:  It wasn't original.

PROF. SCHAUB:  No, no.  You brought it forward in a lovely way.  And I'm certainly in agreement we don't want to, you know, send out surveys to see how we're doing and we don't want to come up with assessment mechanisms or anything like that.  We want to do what we do and give ourselves up to our inquiries in some sense for their own sake.  We're all, you know, scholars, and we trust that there will be those who will read and be effected by our scholarship. 

So I have great sympathy with that, but  I would just point out, Gil, that you're — and Peter also, that you are teachers as well as scholars and the reason that your student read you writings was because you were her teacher first.  And so my opening suggestion was really that the Council think of itself as having a teaching mission as well as a scholarly mission and to give some thought to what that would mean to have a teaching mission.

And let me just add that my notion of teaching is not lecturing the public or being dogmatic in some way, but engaging the public in the same conversations that we've been having or certain portions of the public that we think need to — you know, would benefit from these conversations and to think about ways to find the ways to do that.  And this would be regardless of, you know, what topic we take up in the future.

PROF. LAWLER: Alfonso.

DR. GÓMEZ-LOBO:  On the topic of future themes that we may study, I happen to — after thinking about it a little bit, I think I side with Peter in the sense that I'm not sure it would be wise to have bioethics, per se, as a topic of discussion of the Council.  The reason is this; I'm very skeptical about the field of bioethics, per se.  I think that the real battles are fought not at the bioethics level but at the ethics level and the deep disagreements on philosophical outlook that undergird particular bioethics positions, those are very hard to reconcile, and it would get us into an endless seminar of philosophy here.  And I'm not sure it would be wise to do that. 

I think that we should do our little portion of ethics/bioethics and put forward our arguments and, of course, if there are antagonistic positions in the public, they are going to be discussed.  On the other hand, I happen to think that the topic of children is exceedingly important.  I agree with Mary Ann and those who have spoken about that, because there is tendency to instrumentalization in present day culture.  I mean, technology drives us to see most things as instruments and sometimes I get a sense that even children are viewed as instruments, instruments for one's happiness, instruments for one's prosperity or on the other hand, as obstacles, as instruments that do not yield their fruits.

And that's why I think it is a very important and deep bioethical or ethical question and I sort of suspect that if we start studying it, we're going in for certain surprises.  If we — you know, if we bring in people who have thought about the field, who have had the experience, and deliberating about that seems to me a very important task.

CHAIRMAN KASS: Gil.

PROF. MEILAENDER:  I didn't mean to launch us on a discussion of teaching philosophy.  That was not my intention, though I'd be happy, Diana, sometime to take those questions up with you.  I hate to see you siding with those who want assessment plans or anything. 

(Laughter)

PROF. MEILAENDER:  But I wouldn't want to see us take up bioethics as a topic, not because I don't think there's a lot of important stuff there.  I don't carry any animus against the field and I don't think we do as a body because I think it would focus us really solely on certain kinds of questions of method and that, to me, doesn't seem to be what we're most suited to do or even could do best.  There are two places, one of them — I'm just going to second what's already been mentioned.

One hasn't been mentioned that I think that we could — that are important and that we could profitably do work.  One of them I've mentioned before and we've always shied away from it and we probably shied away from it for very sound reasons, and it would — if we think we've found ourselves in impenetrable thickets on previous occasions it might be even worse, but the whole range of issues surrounding organ donation and transplantation are really very much on the table these days and are very hard to sort through, that kind of working definition, the criterion of when you know someone's dead is under pressure from several different directions.  If you're interested in the commodification issue, the sale of organs or various sort of forms of transaction that perhaps fall a little short of sale, are also there.

So — and even questions just about whether it's always worth it, whether a certain kind of desperation enters in.  Those would all be important questions to ask, though we might find ourselves with more people angry at us than we've already created around the country.  So — but I do think it's an important issue. 

The other one, I think that the children business is important.  I just wanted to add a couple things to the way it's been mentioned.  I mean, in a way it would be nice, if we looked at end-of-life aging, if we looked at children that would be nice.  I think there would be a whole range of questions that haven't been mentioned.  I mean, just to think about how one ought to think about children.  We sometimes may think of them simply as kind of miniature adults and that's not necessarily the right way to think about them. 

In the bioethics literature, they're often just another vulnerable population, along with various — you know, whether that captures everything that one ought to say about them.  The use of children in research is still and will continue to be an important question but not just in scientific research, use of children in advertising.  I mean, there are all sorts of questions one might raise.  Whether we have special responsibilities to children with disabilities.  So there'd be a range of questions one could take up.

Now, you know, whether they'd all fit together into some single project, I'm not sure I could say right now, but it's a very rich topic with a lot of different angles that could certainly profitably be pursued.

CHAIRMAN KASS: Dan Foster.

DR. FOSTER:  I just want to say a brief word in agreement with Frank's initial comments.  You may remember that in the cloning report that the minority group on which I sat, was in favor — voted, was in favor or research cloning and — but it was coupled with the provision that proper regulation be attached.  That was part of the official position that we took under those circumstances, recognizing that there would be certain biological and other dangers associated with these techniques that were worrisome and they should not be carried out freelance.  And so, as a consequence, it's almost necessary for the views of these new techniques that there be some sort of regulation.  We made an attempt to — you know, we'd say, "Well, Congress or whoever shouldn't allow you to make, you know, a human embryo with a goat", or something like that.  You know, there were broad regulations and one thing that we might at least say right now, the probability is that the regulation of these events is going to be vested in the FDA and that may be a wise decision or it may be an unwise decision and it wouldn't be inappropriate, I think, for this group to at least give an accent to what type of regulation might be used, what sort of body might be used even if not giving all the details about how this would go.

I think that this — the reason that I think this is increasingly important is that things are speeding rapidly in terms of stem cell research.  We came up with a White Paper about ways to avoid the embryo question.  I think that's going to happen real fast.  The embryo question is going to disappear and not by the techniques that we talked about, maybe with a variant of Type 4. 

As it turns out, Dick was at the London conference and I have not yet seen the patent, but if it is possible to, in fact, make what has been called the stem-bred, which is a remarkable technique, the details because if there's a patent there or not, but what Yuri Verlinsky in Chicago did was to take a stem cell line, I think I mentioned this before, it's probably one he made himself rather than an NIH stem cell line, and merged it, it was basically a cloning experience, with a somatic cell.  And what he was — and it was a — it was a female cell line and the cell line that he developed was an XY because it was taken from a man.

And so he established — he's established 10 cell lines, at least he's reported, from diseased humans, which is what we want, that's why you want research — the problem with the lines we have, they're all from healthy, in vitro fertilization things.  They're not useful in terms of trying to deal with disease.  If that's the case, if that turns out to be the case, that you can completely avoid the embryo question just by using stem cell lines that are already there as the recipient and establish an immortalized line from Parkinsonism and so forth, then we've immediately got to consider the possibility of injecting these things into humans and things of that sort.

Now, the other — the hybrid model that was just put out, you know, which, you know, you made a heterokaryon, in other words, it was a merging of a somatic cell and a stem cell, and you got a dual nucleus cell to start off with and it differentiated the somatic cell, so it was like a stem cell — the problem with that is you've got to get rid of half of the chromosomes and so forth, and that's going to take a lot longer, but my point I'm trying to make is, that I think the embryo question — I might be wrong, but I think the embryo question is going to disappear because we're going to be able to make these stem cells without having — every having an embryo.  I mean, that was what Bill Hurlbut wanted to do in his model, but once that happens, we've got to have some sort of regulation. 

You know, in the initial DNA things, you know, we've talked about this before, the scientists thought that the RAC committee — we had to decide who was going to get to do and what was going to be approved, you know, the common thing.  So my sort of long comment here is that I believe it would be very important to do what Frank has said, maybe in a broad sense to say, well, there are several models by which one could do this: a scientific model, a regulatory model of the Canadian or UK type, I'm not — I don't care about that, or some modification of the FDA, but somebody is going to have to say what we're going to do.

We're not going to do anything with these lines that we have — that NIH has.  They're worthless because they're drone.  I mean, use them for science, but not for therapy because they're all grown on mice cells, you know.  You got all these viruses and things.  Now, the Koreans, Hwang has  now made cell lines.  He's got 11 that were not grown on animal tissues and so that's also going to push things.  So I think the need for regulation is pretty — is much closer than what we say and the question is well, should we comment on it or just leave it to the other people?  You could argue either way. 

I would prefer for us at least at some point in the next term, to have a suggestion about how  this near imminent possibility of using stem cells and so forth in therapy is going to be controlled.  So I want to speak in terms of at least having us think about that.

I just want to make one other — two other real quick passing responses about whether anybody is going to read what has come out of these volumes.  Very few people will do that, that's true.  I mean, in medicine or science, I mean, there's a huge amount of information and you always long for the people who are practicing to have read the most important new things and oftentimes they don't have time and they don't do that.  And I think that we could — I think that we could say that these reports — and I'm not — let me back off.

At the Lasker Award, Joseph Goldstein, who was the Chairman this last Lasker Award, he had a very interesting analogy and there was a — I don't think I've ever mentioned this, there was an — there was a monument on top of one of the museums which was made out of stones — did I ever — well, the bottom stone weighed two and a half tons and the top one — so it was a pyramid.  And up at the top was a two-pound stone.  Now, Goldstein's point was that there were 550,000 papers published in the medical literature last year, 550,000 in the 4,000 journals at the National Library of Medicine archives, okay? 

And his point was that the mass of information that came out of there was worthless.  That there were only — there was a 2.5 pound set of papers that was importantly new and not trivially new and I think that you just can't worry about that.  I think that in one sense that we probably were in — I mean, what has happened here was really importantly new material that was covered and not everybody is going to read it but that's okay.  I mean, it will still have some influence I think. 

And I'm not so worried about — I don't think you can go on television — look 47 percent of Americans believe that all the species that exist today, existed exactly like they are today from the beginning of time.  Okay, 47 percent of Americans believe that, so robins haven't changed at all.  They've always been exactly — you're not going to be able to deal with that in terms of what we're doing.

The last thing I want to say is that the incentives about a lot of things like health care are so — it's going to be hard to overcome for the commodifications of — I would myself love to talk about transplantation again.  I said that before, but I heard the head of Humana speaking to the Chairs of Medicine one time and he said, and he had an impassioned speech by Tom Andreoli, who was then the Chairman of the University of Medicine Arkansas and he berated him as the head of a big company — You could say the same thing for a big pharma, about their lack of interest in terms of human things and medicine and so forth.

And the CEO said, "You know, it may well be that I would like to give a million dollars from Humana to support the Chairs of Medicine", or whatever he said, "but money is fungible and my first responsibility is to the stockholders.  I can be a cancer like Enron but my job and for all the stockholders is to make money for them and I might personally think that it was good for me to cut the prices of all the drugs such that you could do that, but then money will flee from Humana or from big pharma to another company and we're out of business.  So the incentives to do what we would like to do are very heavy in the very heart of what the capitalistic system is about.  So we shouldn't be — we shouldn't be sanguine about the fact that we can change that to make the health care system more — that has to come from the Government or something of that sort. 

So those are just casual comments, but the main thing is I hope that whoever is on this Council before would look into the issue of at least a broad overview of regulization.  I truly think we're going to need that.

CHAIRMAN KASS: Thank you.  By the way, let me suggest that we not have — despite the — I didn't mean it as an invitation.  No one should take this as an invitation to have an argument about stem cell research, if that's all right.

DR. FOSTER:  No, I don't think you understood me.  I said I think the arguments about stem cell research are going to be over because I don't think we're going to have embryo arguments and I know I've talked too long —

CHAIRMAN KASS: But lest someone rise to correct you on that — I see the hands of some people who might want to do that, and I wanted to tell them, don't. 

PROF. GEORGE:  I promise I won't.

CHAIRMAN KASS: Robby, take the floor.  Turn your mike on.

PROF. GEORGE:  This is not an argument about stem cell research.  I do want to comment on the first half of Dan's remarks but only again by saying that I agree with a very, very large measure of what Dan has said, including the call for us, and I think we are the body to do it, to think about regulatory — at least the procedural issues, the regulatory structures that really should be in place in view of what we know is coming.  Now, without arguing with Dan about the embryonic stem cell issue, I do want to register this; that of course I share Dan's enthusiasm for what Yuri Verlinsky has evidently accomplished, what Kevin Eggan has done at Harvard, Trounsen is doing similar things evidently in Australia and as you know, I've been an enthusiast and a cheerleader for Bill Hurlbut all the way along because I think his proposal is so important and my hope, like yours, Dan, is that we will be able to lay aside the embryo question because we've found a way around it, a way to obtain pluripotent stem cells without embryo destruction.

But I want to say why I fear the issue won't go away and just very briefly, it's this.  I think that the next issue on the embryo front is not going to be blastocyst stage stem cells, but rather the gestation in either an artificial environment or the female volunteer of the embryos for some degree of development after which they would be destroyed and harvested.  I think this issue is coming at us.  I've got an article coming out about this in the Weekly Standard in the next issue but more important and better than my article and I would commend to everybody on the Council to read it, or read them, these are very much worth reading.  Will Saletan has a series, a multi-part series in Slate Magazine online about this question.  So as much as we would all like to put the embryo question behind us and as hopeful as we are that Verlinsky and Eggan and the others, Bill Hurlbut will help us to get over the debate about blastocyst-stage stem cells, I just fear, Dan, that it's going to be with us. 

That doesn't detract in any way from the conclusion that you rightly draw about the need for regulation one way or another, but I just want to register ahat I know is a very uncomfortable point because I, as much as all the rest of the members of the Council, including our distinguished Chairman, would like not to have to argue about this all the time.

CHAIRMAN KASS: Ben has been waiting.

PROF. CARSON:  Actually, a completely different topic.

CHAIRMAN KASS: Good.

PROF. CARSON:  You know, I alluded yesterday to the concept of wellness and I want to just elaborate a little bit on that because, you know, when we're looking at many of these bioethical issues, we're looking at technological advances and how they can be applied, you know, perhaps to eliminating cancer or how we can get to a medication that might get rid of some of the amyloid bodies and perhaps deal with Alzheimer's, but I would hope that at some point we could concentrate on root causes of things because I think, for instance, the environment is a huge bioethical issue.  When we look at the way our environment is being constantly polluted by petroleum products and things. 

And you look at the amount of money, for instance, that has been spent over the last couple of decades by the NCI to get control of cancer and yet, the rates of cancer are actually increasing.  Why is that?  And I personally believe that there are some  major environmental issues and I know there are many others who believe that as well.  I wonder if we could have some of the experts in those areas come and talk to us and begin to maybe formulate some policies about that, because if we can put some science behind it, we might be able to get some real public policy done there. 

If you look at things like the dramatic increase in the number of children diagnosed with attention deficit disorder, you know, why is that?  You know, there have been, you know, a number of proposals, one of which is that it seems to be much more prevalent in this country than in countries where they don't vaccinate children.  Shouldn't we be looking into some of these issues in terms of some of the things that are placed in these vaccinations?  I think that that's a very good charge for a bioethics council.

CHAIRMAN KASS: Thank you very much.  Bill and then Frank.

DR. HURLBUT:  I don't want to reintroduce the embryo question.

CHAIRMAN KASS: I won't let you.

DR. HURLBUT:  But I do want to say this, that in the deliberations that were just referred to, we tried to shift the question off the difficult dilemma of when in the progress of development, the developing human embryo has more value to the question of what, and I think there's no way for us to escape this crucial question of what is the minimal construction that is worthy of human dignity and therefore, protection.

I — for one thing, I agree with Dan about the issue of the embryo but in a strangely different way.  It's not clear — it's becoming increasingly clear that it's not clear what an embryonic stem cell is, what stage of development they would optimally be taken from.  Now it's turned out that via mice there is successful harvesting of embryonic stem cells from the eight-cell stage.  Each stage may have a different property.  I don't think this is just going to be solved by creating stem-breds. 

I think we've sequenced the human genome, are understanding the proteins it produces and now we are entering the age of developmental biology.  From here on out, it's about living organisms and the human living organism.  This means that we can't run away from the issue because as the body charged to deal with the ethical issues of our age, this is the ethical issue of our age.

Now, we don't have to have endless arguments about when an embryo develops moral standing because we have trouble resolving that, but we are going to have to face the issue of at least what is the minimal construction that constitutes a moral entity.  Even reprogramming poses that problem to us.  When I put forward altered nuclear transfer, some professors from Harvard made the comment that you can't define human life on the basis of the absence of one molecule.  Well, I don't agree with them for one thing because that may be the optimal way to do reprogramming, to bring the cell back down to within one molecular type of its human constitution, but the point — the larger point is, we are going to with stem cells, create human parts, apart from the whole of the body.  We're going to have to start defining what is the minimal construction.

Is a brain with one sensory modality worthy of protection?  I mean, that's a science fiction scenario, but we need to start understanding. If we're going to grow human parts apart from their place in the living whole, we need to come to terms with the commodification questions that are involved in growing whole organs, maybe even organ systems in factories or such settings.  We need to face the question that Robby posed, that embryogenesis requires complex micro-environments for its — for the successful differentiation of cells, tissues and organs and the question of whether there are possibilities for growing systems that are actually evolving in terms of development that are still ethical because they don't constitute organismal wholes. 

I just don't see how we can avoid this.  We have to face the questions of human-animal chimerizations, the complex questions that may be summed up with the term the boundaries of humanity.  So I would urge us not to flee from that which is running toward us.  There's a saying in Russia, "When the dog runs at you, whistle."  I think this — just to carry this one step further, I think it means that we need to develop effective tools for collaboration with the scientific community in order to help foster and encourage and even help the public come to accept some of the less easily intuitive positive possibilities of scientific advance and so I'd like to see a way to work in really positive ways with the scientific community and also agree that that will mean that we have to find ways to cooperate in the establishment of some regulations. 

And just to add a couple more points of further projects that hinge off of this, I've been doing quite a bit of international travel in the last couple of years and specifically, I was in Asia this summer.  And I think we have to face into the very profound significance of the global community on these ethical issues.  Part of our mandate originally was to — I can't remember the exact quote but, "Develop cooperative collaborations on an international level", and I don't think we've effectively done that, although we've had some testimony from other countries.  I'm frankly, worried about the significance of a world where arguments are made, "We have to do it here because they're doing it there."  That seems to me not a good argument, but more importantly, there's the omnipresent danger of the — what you might call the outsourcing of unethical practices, if we can't do it here, we'll get it done over there.

Now, obviously, we can't even figure out a way to regulate our own country, we're not going to regulate the world, but I think we need to start working in some measure of initial thoughtfulness as to how we can establish cooperative international collaborations.  And I think, just to hinge on what Ben said, we are increasingly coming to understand, those of us with scientific training, how subtle and fragile biological systems actually are and how little tiny things like any one of the 80,000 industrial chemicals in our environment, artificial chemicals, might be altering something of crucial human significance. 

I'm not saying it's associated with vaccinations or with the — you know, the artificial chemical in your couch or something but some — for some reason there's an increase in autism.  We have to face these questions.  There's this weird issue of phthalates.  What are they doing to the next generation's fertility?  And that would be a good public education thing. 

CHAIRMAN KASS: Do you want to conclude?

DR. HURLBUT:  What?

CHAIRMAN KASS: Do you want to conclude?

CHAIRMAN KASS: Pardon me?

CHAIRMAN KASS: Would you —

DR. HURLBUT:  Wrap it up.

CHAIRMAN KASS: — move to the end.

DR. HURLBUT:  Yeah.  The other thing is I really think we need to face into the — on an international level, the fundamental danger of biotechnology tapping into our most primary desires because I think what's happening to us as a society is we're using biotechnology to short-circuit that which we've always wanted to have in terms of media pleasures, sense of personal ideals of appearance and performance and so forth. 

That creates a very significant situation with the danger of desire magnifying our powers to get what we want, putting a preoccupation in our minds of what naturally is a positive desire but unrestrained with biotechnology becomes a preoccupation or vanity and even a selfishness and with 30,000 kids dying on average every day in the world, it seems to me that we could use biotechnology to become — enhance our own vanity rather than increasing our goodness in the world.

And in that sense, I think we could end up being a society of addicts to short-term goals instead of the comprehensive good.  And finally, I'd like to say that I would hope in the next session we might consider the possibility of maybe having a Volume 2 of our anthology of literature because we really need to extend the positive resources and the affirmation that these bioethical issues are profound issues around which there's been a great deal of thought in human experience and wisdom traditions.

CHAIRMAN KASS: We are roughly at the end of this session.  Let me — I want to introduce a comment that I received from our colleague, Mike Gazzaniga, who couldn't make this meeting on the issue of new topics.  "I continue to believe that a full examination of health practices in America would be a great topic, the short version," and Mike likes the short version although he's introduced this to us before.  "Have Americans been oversold on the need to see a doctor?  Health benefits are bankrupting the country and institutions.  I see this as a problem both from a practical and ethical perspective".  And this ties into the presentation that we had from John Wennberg at a previous meeting on what are all these costly interventions actually getting us.

Since I haven't said anything, indulge me three suggestions of things that I think might be put on the table, and if you don't mind, maybe I will try — once I've read the transcript, try to distill some of the positive suggestions of topics into a kind of memorandum to be circulated to all of you for amendment and addition and make this my gift to the new Chairman for his consideration for our collective consideration.  So I'll try to distill some of this and you'll all have a chance to add and develop it.

But I think I would like to underscore the children's topic.  It was — we touched on it most especially in "Beyond Therapy" on the uses of psychotropic drugs as well as questions of choosing sex of children, questions both of a practical and theoretical sort.  How to get a handle on this, whether one should really talk about the medication of children or the kinds of things that will give rise to the increased incidences of these disorders in children, God knows why.  I think that would be a terribly important subject dealing with children not only because they're vulnerable and don't have advocates, but because they really are our future and we owe it to ourselves to bring our best thinking and ethical reflection to bear on this.

Second, this is only sort of tacitly mentioned really in Rebecca's comment but it was very prominent in yesterday's first discussion, I believe, where we were talking really about sort of the ethical dimensions of the access question, not the political arguments, not the economic arguments and not to put it — Peter observed yesterday that this Council doesn't generally speak a lot in terms of rights.  We tend to speak in terms of good.  And then the question is what does a decent and a good community in fact owe to those of its members who are unable, in fact, to provide for themselves in a way in which they would like if only they could?

And I think the aging topic is only one piece of it.  And one has to find some kind of manageable way to do this, but to do this in a serious way, not simply to become an advocacy group for a particular point of view, but try to really sort out how to think about this in a constructive way.  That would be, I think, an important contribution.

This is the case that all third things today I'm not going to remember.  One was the children, one was this — oh, yes, the third thing has to do with what we'll talk about after the break.  Government regulation is one thing that we have considered, but regulatio, as the report we issued makes perfectly clear, if you understand regulation broadly to include things like tort laws, professional standards, et cetera, so many of the things we talk about enter into the lives of ourselves and our fellow citizens really through the good offices of the medical profession.  And some reflection on the character of the profession, the medical calling and its own professional self-regulation, a topic, I know, very dear to Ed Pellegrino's heart, but one which we've touched on tangentially but have never really taken up, especially in its new context, an age no longer of lore, not to speak of Hippocrates, but where you've got all of these commercial interests and the changing practice, do we have something useful to say about how to shore up, to articulate the medical vocation today in its current circumstances and to offer something useful on that subject I think might be another large thing that cuts across the small topics but one on which under the new leadership, I think we would be very well poised to say something.

Unless somebody has an epiphany or — it needn't be an epiphany.  Frank, you had your hand up before.  Please, take the last comment and then we'll break.

PROF. FUKUYAMA:  Well, this is a suggestion for a new topic.  I think there ought to be some investigation of non-Western ethical systems and what they imply for the future of biomedicine.  There was a KBS team in here that interviewed, I think, Rebecca and me from Korea and they had this question, "Well, what do you think of Dr. Hwang and don't you think that your high ethical standards are holding you back, you Americans, while we Koreans race forward"?

It is — and I think that we ought to — it ought to be looked at not as, you know, let's see Asia as a zone of unethical practice but really from internal to those ethical systems, what implications does it have for the way biomedicine is going to develop in those countries?  One thing — I mean, I can give a seminar on ethics in Asia, but one thing for example is extremely clear, the bright line that the Judeo-Christian tradition draws between human and non-human that invests human beings with dignity simply is not supported by any of the ethical systems in Asia.

Buddism, you know, Taoism and Shinto are polytheistic religions, you know, so that everything is invested with spirituality in a certain sense.  Hinduism and Buddhism, you know, both have doctrines of reincarnation where you can come back as an animal and it has interesting effects because it gives — in those ethical systems non-human creation has a higher moral status and so it's quite interesting. The Japanese primatologists were the first to notice that actually certain classes of macaques actually had culture that could be transmitted.  They're more open to this idea that non-human creatures have, you know, a higher degree of dignity but this idea that, you know, there's this moral status that switches on simply because you're born a human being is really not supported by any of those systems.

And I think you need to — and democracy in Asia is not going to solve this question, you know.  This is a problem in democratic Japan, democratic South Korea.  There's simply different, you know, ways of looking at the world, and since so much of the science is going to come out of that part of the world, I think that we owe it to ourselves to educate ourselves a little bit about what some of these alternative, you know, ways of looking at these issues are. 

CHAIRMAN KASS: Thank you very much.  Seventeen Council members and 18 opinions.  We'll try to sort out some of these comments and give you a memo before you take the Chair. 

We're adjourned.  I don't want to steal too much time from the discussion of the story, so please return promptly in 15 minutes.  I know some colleagues have to leave early.

(A brief recess was taken at 10:12 a.m.)