Meeting Transcript
November 8, 2007

Council Members Present

Edmund Pellegrino, M.D., Chairman
Georgetown University

Floyd E. Bloom, M.D.
Scripps Research Institute

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

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

Nicholas N. Eberstadt, Ph.D.
American Enterprise Institute

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

Michael S. Gazzaniga, Ph.D.
University of California, Santa Barbara

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

Alfonso Gómez-Lobo, Dr.phil.
Georgetown University

William B. Hurlbut, M.D.
Stanford University

Peter A. Lawler, Ph.D.
Berry College

Paul McHugh, M.D.
Johns Hopkins Hospital

Diana J. Schaub, Ph.D.
Loyola College

Carl E. Schneider, J.D.
University of Michigan

INDEX

• Session 1: The Healing Professions/Medicine
  
• Session 2: The Healing Professions/Medicine
  
• Session 3: The Healing Professions/Medicine
  
• Session 4: The Ethical Foundations of Health Care
  

   

CHAIRMAN PELLEGRINO:  Good morning.  Welcome.   The first act of business is to recognize Dr.  Daniel Davis, the Executive Director of the Council, who is the official government representative at this meeting.  Dan, good to have you with us.  

This meeting will be dedicated to several subjects we've been dealing with over the last several meetings, and I'm hoping that each and every one of you on the Council will, as you make comments and any comments you want to add later, comment on the appropriateness of these subjects and whether we should or should not pursue them and in what way the Council can make a contribution to these subjects as well.

And without further ado, I will do as we generally do, begin without a formal introduction.  For the members of the Council, the background of our first speaker, Arthur Frank, is in the agenda book and I will identify him as from the University of Calgary.  He and I have had a meeting some years ago.  We were trying to reconstruct when it was.  His memory is better than mine, but neither of us could recall that.  But I'm sure, since I wasn't talking, he probably had a good time.

Dr.  Frank is going to take up the question of the healing professions, medicine, being a paradigm case, but certainly not the only one of the healing professions.  And we invite him to make his presentation, following which we will have a member of the Council open the discussion.

Dr.  Frank, you may use the podium if you wish, or the chair, whichever you like.

PROF.  FRANK:  No.  I was just figuring out how to turn my microphone on.  Thank you, Dr.  Pellegrino.   Thank you for inviting me.  And because our topic, my topic, this morning really is how to achieve kindness in highly administered bureaucratic settings, I want to thank Emily Jones for her help getting me down here.   She exemplified the qualities I want to describe this morning.  I'm not sure Emily is still in the room, but thanks very much to her.

My presentation this morning attempts to address the Council's concerns by adding a more practical dimension to the project expressed by the title of my most recent book, The Renewal of Generosity.  Simply put, even when healthcare offers good treatment, it too rarely offers generous care.  My concern is how care can be, not only safe and competent, but also generous.

Because I appear in a series of speakers on the professions, let me begin with a preface in which I'd like to reframe the question of professional crisis and renewal.  My perspective is formed in part by my work with practicing physicians and nurses, but it's also formed by several decades of teaching sociological theory, in which the figure of the professional has a specific and crucial role.  How I see things is also affected by my currently writing a book about how stories enable human life.

I understand social theories as narratives that seek to make livable the tensions of modernity.  One tradition of theory undertakes a defense of modernity, and certainly since Marx, modernity has required defending.  In these narratives of modernity, the professional is cast to play the role of hero.  I mean hero in the tradition of Germanic mythology, in which the trouble that animates the story is a crack in the foundation of the house of the gods.  The hero exists in order to hold that crack together, lest it expand and bring down the gods' house.  In other words, life is a constant struggle between forces of light, the gods, and darkness, which the fall of the gods would bring.

The hero is one who, in his being as much as in his deeds, sustains the forces of light that are always threatened by this crack in the foundation, and that's a core narrative.  Sociology takes up this narrative, casting the professional in the heroic role of holding together a modernity that even its defenders admit is cracked. 

At the start of the 20th century, Emile Durkheim hopes that professional associations will mediate between governments that are too big and distant, and families that are too small and local.  Max Weber emphasizes the professionalism of the administrative bureaucracy.  Thorstein Veblen, for whom modernity is definitely cracked, looks to engineers to save the world through their technical and managerial expertise.  And so it goes in this tradition, culminating at mid-century with Talcott Parsons, for whom the physician represents the historical telos of the professions and the measure of other professionals. 

For Parsons, the physician unifies the competing aspects of modernity:  the drive to personal gain and the drive to collective good.  In the physician's independent practice, he — and my pronoun reflects that I'm talking about the 1940s and '50s — is an entrepreneur, making a living from fees received.  But in the physician's professional obligations, he puts the welfare of his patients before financial gain.  Thus, the professional-as-physician is the hero who, in his being, embodies the reconciliation between the forces of capitalist self-aggrandizement through financial gain — which is the typical motive of the businessperson — and the forces of collective good, represented by religions and state welfare institutions.  The professional physician literally heals modernity, holding together the cracked sides of its internal fault.  Following Durkheim, Parsons understood this crack as the potential for forces of egoistic self-aggrandizement — unleashed by capitalism — to overwhelm obligations to collective need.

At least two questions can now be asked, and I will only pose these, not pursue them.  You have already heard speakers who have shed considerable light on both of these questions.

The first is:  to the extent that this theoretical idealization of the professions, especially of the physician, was ever actually true as a representation of people's lives and experiences, was that because particular historical circumstances came together for several decades, but this specific figuration could not be expected to persist?  Is it possible that in mid-century >America, there was a historically unique balance?  Physicians had sufficient resources of knowledge and technology to be able to offer real benefits to many patients, but these benefits were still sufficiently limited so that demand was not yet excessive, and the means of medical practice were still sufficiently low-tech and low-investment that there was not yet an excessively tempting amount of money in play?  I pose that as one kind of question, or as a hypothesis for a historical investigation.

The second question follows from the first and is the point of this preface.  If the heroic narrative has had its day; if as Max Weber once wrote, the light of the great cultural problems has moved on, what is left?  Here I get to generosity.  What is left is what I have called fundamental medicine:  two human beings in a room, one who is in need, and the other who has at least limited resources to meet that need.

There is a crack in the foundation of this room.  One side of this crack is a level of need that can overwhelm the capacity to offer medical care.  Today, the needs of patients have a potential for almost limitless expansion.  Some of this expansion is in response to the perceived benefits of medicine.  A different kind of expansion stems from medicine's job as a repair center of last resort for people whose bodies reflect the physical degradation of the condition of their lives and work, because there is no other reliable care system. 

The other side of the crack is the increasing commercialization of medicine that Dr. Relman spoke about.  I see commercialization as Dr. Relman does.  Yet, my own meetings with medical students, unsystematic as my sample is, support the recent study by the American Association of Medical Colleges finding that young physicians, as a group, are less interested in massive financial gain than in living balanced lives. 

If I find those young physicians' attitudes to be a cause for optimism, I also recognize that the directions of the profession are being set by forces well described by Drs. Sheila and David Rothman.  Whatever individual doctors may want, physicians are being cast as the point-of-sale delivery agents for a huge commercial enterprise, including but hardly limited to the pharmaceutical industry.  This enterprise wants its products to reach consumers.  Like all good capitalist enterprises, medical commerce has scarce interest in matter of equality,  specifically no interest in how the distribution of its products affects what we can call the social gradient — who has access to what resources, in order to advance their lives in what ways, including marketplace advancement.  For the medical-industrial complex, "consumer-driven" means gearing the nature and the delivery of services to those with the greatest ability to pay. 

So how can healthcare — not just physicians but all those whose work and whose presence affects patients — how can healthcare remain generous, in the middle of this crack between expanding need and demand, and expanding pressure to deliver treatments as commodities?  And, why do I keep my focus on this small room in which fundamental medicine is being practiced, when as I have emphasized, so many external factors are pressing in on that room, affecting what can happen there?  Why, when so many big issues seem to require macro-level reform, do I keep on thinking so small?

To create a narrative of generous medicine, I have needed a helper, and this has taken the form of a personification that I call the Dialogical Stoic, which is a slight philosophical joke.  Yet, the Dialogical Stoic reflects real needs of both seriously ill patients and professional caregivers.  I begin with the needs of patients, because my own direct experience is on the side of the person in need.

Being seriously ill requires two complementary but distinct capacities.  One is the capacity to be alone, both in the literal sense of being by yourself and in the expanded sense of feeling you have only internal resources to get you through what you confront.  Stoicism begins with sorting out what a person can control from what she or he cannot change or affect.  The point of this differentiation is to take the fullest responsibility for what is yours, and to be neither distracted nor distraught by what is not yours.  That is one competence required of the seriously ill.  The complementary competence is living a life that is dependent on the physical care and the moral recognition of others.  I call this competence dialogical because it involves a play of voices.  In care that is dialogical, the voice of each comes to speak the voice of the other; boundaries of self and other remain, but become permeable.  Each sees and hears him or herself in the other, not as identification, but as an effect of mutual recognition. 

Healthcare professionals also have their Stoic moments and their dialogical moments.  Here I include as professionals everyone from physicians and nurses down the institutional hierarchy through technicians to admission clerks and porters, because all these workers are pursuing a calling of offering themselves — their bodies as well as their skills — to other humans who are in need. 

For professionals, the Stoic moment is a refusal of the alibi that because my work is affected by so many rules, constraints, and codes — from billing codes to codes of conduct — any limitations in how I act reflect the limitations of my situation and supports, or lack of supports.  Again, the Stoic begins by taking account of all that she or he cannot be responsible for, but not as an alibi.  Instead, the Stoic uses this separation as a foundation for taking the fullest responsibility for what she or he can do, living a life responsive to others' needs. 

The complementary dialogical moment for the professional involves recognizing what it means to be present to those who suffer.  Dialogical presence is physical — one's body is close to the other's body  —  it is moral, and it is mutual.  The dialogical moment involves seeing beyond all the limitation and frustration to the fulfillment described in the testimony of so many caregivers.  In caring for the suffering other, they discover that their own deepest needs are being met.  Like all ideals, this dialogical ideal is easily overwhelmed.  The question is how to sustain its possibility. 

From the perspective of the Dialogical Stoic, the problem in contemporary healthcare is that everyone — patients and their families, physicians and other healthcare professionals — everyone is waiting for Godot, where Godot is the algebraic X that is filled in by whatever comes from elsewhere and sustains the fantasy that something-from-elsewhere is what we need to solve our problems and restore meaning and goodness to life.  For some person, Godot is a breakthrough drug.  For another, it's reform of the reimbursement system.  For yet another, Godot is new management that will open its eyes and actually see how its policies affect professionals' ability to care. 

The problem of care, of generous care, is that so many people feel like their work and lives are hostages to what only someone else could provide, but is not providing for some reason or another.  So people act as if they can only wait, and become more demoralized, and eventually seem to forget what they were waiting for.  People become what Robert Merton, back in the late 1930s, called ritualists:  they keep on fulfilling their job requirements, but they have given up on their work fulfilling the values and goals that they once felt invested in.  What both Stoicism and dialogism teach, as a practical ethic, is how to avoid living your life like a hostage.  My positive word for this negative injunction is generosity.

People do not feel like hostages because of some failure in their personalities.  They feel that way because the material conditions of their lives and work encourage that feeling.  Healthcare today is heavily routinized, if I can use a sociological term that seems most appropriate.  That is, caring is reduced to routines that have their specific jargon and algorithms.  In the United States, care is mediated by Length of Stay data, as a measure of hospital and physician efficiency; in Australia, there is protocol-based nursing; in Canada, we have clinical pathways that determine exactly when the patient is supposed to need what or be ready for what, culminating in discharge.  These routines reduce professionals — a term implying both competence and independence of judgment — to workers, implying those who implement directions from elsewhere. 

I want to recognize two aspects of this routinization of care.  One is that it begins with a generous impulse, and the other is that it demoralizes patients, families, and professionals.  The generous impulse is to offer the highest standard of care to the greatest number of patients.  Unfortunately, standardizing care means that particular patients will suffer because their needs do not fit the standardization.  Serving the greatest number means that some will suffer so that others can benefit.  The impulses behind routinization may be generous, but being the object of routinized care, as a patient, or having to practice routinized care as a professional, is demoralizing, because sooner or later, either one's own needs are denied or one has to act as the agent of such denial.  Routinization sucks the generosity out of people, leaving them hollow.

If there is, today, a crisis in the professions, I see it on two complementary levels.  On the level of fundamental medicine, the crisis is the disconnection between, on the one side, a patient and a family for whom how they deal, right now, with this illness is the crucial measure of their moral lives.  On the other side of this disconnection is a professional who is trying to meet an administratively imposed standard of expectations, and who has been shaped by those administrative standards into a functionary, for whom this patient and family present nothing requiring distinctive recognition.  To use a Canadian metaphor, these are the two solitudes of healthcare.  And each does feel utterly alone. 

So after all this exposition, why do I think small?  Because despite all the external pressures on the two people in this small room where fundamental medicine is practiced, there can be dialogue between them, and in that dialogue there can be recognition of suffering and there can be care.  For this dialogue to happen, each must effect a stoic separation between what each remains capable of — which is responding to the face of the other, in its singularity and need — and what each cannot be responsible for, which may include the length of time they have together or the scope of services that can be offered.

I think small because I believe that people can have the courage to stop waiting for whatever Godot is supposed to make their lives better.  People can begin to do what they can, with what they have now, to make their lives better.  An important corollary belief follows.  The most effective and efficient way to bring about changes is to act as if they had already taken place, and the benefits can be realized right now.  Utopian as this belief sounds, it reflects a realistic recognition that the 20th Century is littered with the bones of well-meaning reforms that either went nowhere or turned distinctly bad.  Maybe the lesson is that whatever macro-reform is enacted, its eventual effects will depend less on the higher-level planning of that reform and more on the spirit — the morale and the morality — of people who implement those reforms at the point of practice.  The fate of any reform seems to hinge on the character of people who implement that reform.  So, of course, I agree health care requires structural reform.  But that is not a crisis.  That is an historical constant, and it's definitional of modernity.  The crisis is the moral character of those who are practicing healthcare today and who will implement changes in healthcare tomorrow. 

How to enable people's capacity to express moral character brings me to practical generosity.  Here I offer a proposal that truly is modest, at least in its implementation.  What seems realistic is to draw upon one of the great institutional innovations of the last century, which is the recovery group.  Recovery groups are justly criticized from multiple perspectives.  Yet, the fundamentals of the recovery model appeal to a Dialogical Stoic.  At the core of the recovery model is sorting out what a person can control and cannot control, and resolving to work on the former and not be demoralized by the latter.  Moreover, recovery groups trust the power of dialogue to affect lives.  Recovery dialogue is often overly constrained by group ideologies — it's by no means perfect — but the group is committed to hearing and learning from each other's stories. 

What I offer, as a plan for practical generosity, is a one-off recovery model, a 13-step  program for someone whom I think of as a recovering caregiver.  Recovering caregivers suspect that in the battle for their hearts and minds, the best part of their moral selves has been lost.  That is, a capacity for care as response of one human to another has given way to a routinized response of workers to clients.  My prototype candidate of someone who needs to be a recovering caregiver is the physician who is quoted by Charles Bosk in his book, All God's Mistakes, about genetic counseling.  Bosk is asking this physician how he can keep on working in a hospital where things happen as they do.  The physician's response epitomizes the loss of a person's heart and mind:  "What you have to do is this, Bosk.  When you get up in the morning, pretend your car is a spaceship.  Tell yourself you are going to visit another planet.  You say, 'On that planet terrible things happen, but they don't happen on my planet.  They only happen on that planet I take my spaceship to each morning.'"  What does this spaceship physician need, to renew generosity in his life?  In offering my 13-step recovery program, I am well aware that multiple professional associations have worked hard to produce different pledges, codes, and guidelines.  Why do I, without the benefit of even being a healthcare professional, have the presumption to offer another statement of good intentions?  The answer has to be that mine are somehow different; how?  What I find in reading the pledges and codes of professional associations is that they take everyday practices up into the elevated thin air of principles.  These principles are laudable, but they often sound too much like ceremonial pronouncements made on ritual occasions; they seem disconnected from the practical realities that I hear in professionals' descriptions of their frustrations and joys in medical work.  I have tried to write not principles, but behaviorals:  my statements seek to help people to reflect on whether they are acting as they want to.  I've tried to write statements that seem simple, but then have a kind of aftertaste that leaves people wondering whether they are actually doing what the resolution recommends, and what the extent of that resolution is. 

I have also tried to include moments of permission in my one-off 13-steps.  Too many pledges are all obligation.  Stoicism balances responsibilities with letting go; letting go is prerequisite to assuming responsibility.  So several of my statements allow the recovering caregiver to let go, by encouraging reflection of what the person cannot take responsibility for.

Unlike other 12-step recovery programs, I offer these 13-steps not as a canonical statement that must be observed without variation.  These steps are an opening to peer dialogue that will lead to revision of how steps are worded, to the deletion of some steps, and to addition of others.  I would be most happy if peer groups of two or three or twelve took my 13 steps apart completely and wrote their own.  What would count for me is that I had at least instigated that degree of commitment to moral reflection on practices of care, and that much dialogue about practice.  I believe that if the Stoic from whom I have learned the most, Marcus Aurelius, were to return to earth and see people reading his injunctions for living, his comment would be that it was fine to read his writing once to get the idea of the exercise, but what counted was people undertaking the work of writing their own injunctions, reminding themselves of how to meet whatever challenges their ability to sustain their integrity of character. 

Here, then, are my 13-steps — and there's a handout that will be passed around as soon as I'm finished.  Or, my 13 provisional resolutions, offered for dialogue and revision by professionals who feel a need to reflect on what care means in their lives and their conditions of work. 

            1.  Any expertise or skill I offer is based, first and last, on offering my presence as a fellow human being. 

            2.  My words and gestures, and the attitudes I project through my actions, affect the healing of my patients, the morale of my co-workers, and the moral self I become. 

            3.  I am responsible for how I offer care, but I do not work in conditions of my own choosing. 

            4.  I forgive myself for doing what my working conditions require, but forgiveness requires working to change whatever is detrimental to care. 

            5.  If I ever feel my work is out of my control, then I have ceased to be an effective professional and need either a day off, or to lead a protest, or both.

            6.  I refuse to blame patients when their troubles reveal inadequacies of either professional institutional capacity to care or professional ability to treat. 

            7.  I will recognize who — patient, co-worker, or myself — pays what price in which currency — money, time, physical risk, dignity — to keep the institution running.

            8.  I will ask myself:  By telling or not telling a truth at this moment, whom is that serving?

            9.  I refuse the self-defense of blindness to the gap between my patients' needs and what care I can offer.

            10.  When I reach the limit of my ability to provide care, I will recognize what remains uncared for and offer appropriate expressions of regret. 

            11.  Faced with patients or co-workers whom I find difficult, I will first ask myself what difficulties they confront, and how they are struggling to hold their own.  If recognizing their struggle fails to bring resolution, I will protect myself.

            12.  I will never forget that any person's suffering is every other human's vulnerability, including my own. 

            13.  I will seek, in each person, what is most admirable, enjoyable, and soulful.  I choose to respond to these qualities with what is best in me. 

I emphasize in closing that implementing this program for the renewal of generosity requires nothing more than two people sharing an aspiration to put caring back at the center of their professional lives.  There is no need to take control of a professional association, or to plan a national strategy for equitable healthcare, or to alter the corporate development and production of health resources.  There is no need for agreement on what big goals might mean or how to achieve them.  There are just practices of care, reflected upon and refined through dialogue about how we — as some group of professionals, including the physicians and the porters — want to live our working, professional lives, and what we owe to ourselves in how we care for these fellow humans, our patients. 

As people experience themselves being the caregivers they choose to be, they will feel less like hostages and more like those whose lives fulfill a calling.  Eventually, my belief, and maybe my faith, is that when enough small groups put generosity into practice, then institutional policy changes will follow.  The changes that have the greatest chance of having an effect and of turning out for the good are those that enable what is best in what is already being done.  These changes will seem natural ways to catch up with practices that have already shown people what they can do, to be who they want to be.  Then people will say, we did it ourselves.

Thank you, Dr. Pellegrino.

CHAIRMAN PELLEGRINO:  Thank you very much, Professor Frank.  We're very much appreciative of your insight into the beginning and the end of medical care which is with the bedside of the patient, the clinic of the patient, and the confrontation person-to-person.

We have asked Dr. Rebecca Dresser, a member of the Council, to open the discussion.  Dr. Dresser?

PROF. DRESSER:  Thank you.  I'm honored to begin because I'm a big fan of Dr. Frank.  I was introduced to you and your work about 12 years ago by another Council member, Carl Schneider, and at that time, you had just published your book, The Wounded Storyteller. 

In there you wrote, "People who tell stories of illness are witnesses turning illness into moral responsibility."  With power and compassion, you have been such a witness and many have benefited. 

Now in that book and your earlier one, At the Will of the Body, your thoughts about fundamental medicine came primarily from the perspective of the patient.  And there's appreciation there for health professionals, but there's also a lot of anger and criticism about their behavior.  Some of your other work though and the presentation today focuses more on the professional and from the professional's perspective of healthcare, so perhaps you have come to feel more generous to healthcare professionals in the time that has elapsed.  If so, I'd like to hear about that evolution.  You elude to it in the reading, but I'd like to hear more about that and also how your experience as a seriously ill patient connect and fit into the practices of care that you've presented to us.

And then finally, in the article that we read, "Generous Medicine," you talk about a conversation that physicians can have with patients if they want to help the patient, and you describe some basic questions physicians can ask that are focused on how has the illness changed your life.  I wonder if you have some questions, thoughts, about more specific situations; for example, the situation of breaking bad news to a patient, talking to a patient who is refusing treatment that the physician thinks is beneficial.  What questions might the general physician ask patients in those contexts?

CHAIRMAN PELLEGRINO:  Dr. Frank?

PROF. FRANK:  I assume this meeting is going late into the evening to respond to all of those.           

Thank you for that lovely summary of where I've been and excuse me if I reply fairly selectively to an extremely global question that you've put to me.

You're right.  I have changed my attitudes toward professionals.  Maybe because it's been, very happily, a long time since I've been seriously ill, although I've continued to go through serious illness with people who are very close to me, and I've seen both their frustrations but also how incredibly much they've been helped by physicians.

It's also that so many physicians over the last 15 years have been so extremely kind to me in terms of, not just in inviting me to speak various places, but really taking me into their confidence and talking to me so candidly and movingly about their joys and frustrations, as I said, and I've really gotten to know these people.

This year I have the privilege of having a group of medical students whom I meet with on a sort of regularly irregular basis and just talking to them about everything they want to hold onto as they move into professional life, and I want so much to do what I can to help them to be able to hold onto what's best in themselves.

And, of course, we have a long literature on what happens to medical students, and it's one of the most depressing literatures you can read because, ever since Boys in White studying medical students back in the late '40s, the story has been exactly the same.  You start off with these incredibly idealistic, highly motivated young people, and you produce cynics and skeptics.  And really the only thing that's changed much in that literature is where the production takes place, whether it happens toward the end of medical school or now it seems to happen more during residency periods, but we could call it the institutional production of cynicism.  It's really the lesson of that literature.

So how do we help these people stay who they are?  That's been the big question for half a century.  And people are doing an enormous amount of work about that.  I also work with people involved in medical education.  They're acutely aware of this. So I'm trying to do my small bit to contribute to this effort, and that's part of the presentation today.

In terms of my experiences, it's a matter of thinking through everything, whether it's a medical-economic question or whether it's a question of professional identity in terms of what its impact is going to be on those who are most vulnerable and most in suffering now.

The fundamental asymmetry of the medical encounter, of what I'm calling fundamental medicine, may not be differential expertise, may not be differential access to resources.  It's the fact that something is going on in one person's body which is terrifying.  They're frightened.  That's their vulnerability.  The rug is getting pulled out from under their lives.  And the other person has the grace to be enjoying another day at the office, and that's really the divide that has to be crossed.

So how do we think through every single question in terms of what it is like to be this person who is perhaps in pain, most certainly afraid, uncertain, wondering where this is going to go?   How do we always see it from that perspective and the perspective of the person who has the least resources to deal with the situation?  I take a lot of this from liberation theology which I think is extremely important as a moral foundation. 

In terms of your notion of questions, rather than pose more specific questions on this occasion, that is questions — you mentioned bad news, or patients who seem ill-advised and refusing treatment. I think that way lies at the core of these impasses, these sticking points — it's very often that one person simply doesn't know enough about how the other person is trying — and the phrase I like to use — trying to hold their own.  And a lot of the impasses can seem much more resolvable if some background questions are asked about the person's life if you maybe just step back from the immediate impasse and find out something about where this person has come from.

The greatest rounds I was ever asked to do in a hospital, the greatest in the sense of the most fun and, I think, the most productive, was a small hospital in Chicago, and they brought in someone who was their "difficult patient" for me to talk to.  And I started off talking to her, but not about the things that were of concern to the medical staff at that moment.  I noticed that she was born in the early '20s.  I said, "So you were kind of eight or nine when the Depression started.  Did you notice this?  Did it have much effect on your life?"  Wow, did it ever, and she took off, and she told us this incredible saga about a life that included all kinds of enormously difficult circumstances.  And I asked her just some kind of generals helping along the way to keep her telling the story of her life.

The two points of this:  One, when we got to the end, the attending physician whose patient she was officially, although she was cared for by everybody there, pointed out that it had only taken 20 minutes.  Now this is someone with advanced diabetes, at that point was in and out of the hospital monthly, eventually was in the hospital fulltime.  For the hours of care, the days, you know, all the institutional resources, 20 minutes was nothing.

The second point was that in the followup that he was kind enough to send to me a lot of these difficulties just seemed to fade away because she felt she was being treated by people who knew who she was, where she came from, how she was trying to hold her own, and how her present difficulty was part of that holding her own.   And they realized who they were dealing with, that this morbidly-obese, eccentric old lady had a story.  It was an incredible story. 

Thanks.

CHAIRMAN PELLEGRINO:  Thank you very much.  The paper is now open for discussion.  Bill?

DR. HURLBUT:  Well, I think you've clearly identified and described the disease, but I want to ask you about the diagnosis a little bit and the etiology, if you will, implicit in the diagnosis.

You began with this comment about the crack in modernity, and reflecting on that as you were speaking, I was thinking about the meaning of the word "modernity," which has an interesting kind of source in that it's rooted in the notion of a concept of a measure or a manner, particularly of or pertaining to present times.  And it comes from the same Latin root, I guess, that the word "module" does, the idea that there is a kind of interchangeability of things and things — and we all know what this is about.  It's a sense of, well, this is our way of seeing the world.  This is our era.  It's not every era. 

And what strikes me is that you're calling for very deep things here, the concept of generosity and its relationship to both suffering and gratitude.  You cite this notion of this spaceship, and I remember very well my early days of training in medical school, what it was like.  You enter into a realm that is largely sequestered into a special zone in our civilization.  It's not in a lot of past (and some present) societies.  But suddenly as a medical student you're thrown into an encounter with suffering, with death, that you don't really experience, at least not in most suburban existence and relatively affluent urban existence.  It's a dramatic and powerful encounter. 

You immediately are besieged by a reality that is not one you've adjusted your life and philosophy to for the previous decades.  And medical students typically go through a phase that's sometimes called "medical student disease" where they start finding the symptoms of the diseases they're encountering in their own bodies and actually are going through a very trying and troubling and sometimes very difficult transition to an acknowledgement of their own frailty and finitude, their own mortality actually.

Well, what I want to ask you about is basically this.  It struck me at the time of my training and it strikes me now that the crack in modernity is really a crack in creation or at least in the way that creation is operating.

It's the reality of something that is not easy to accommodate, namely, death.  And you've laid out some very good ideas here.  I certainly concur with the central themes of your 13 steps.  But I wonder if the diagnosis isn't deeper and if the cure more fundamental; namely, to say that we need a prevailing philosophy in our civilization that actually directly contends with the mystery of human life and death.

I think when I've observed people caring for others in the manner that you describe it usually comes from something very profound where they are no longer hiding from basic reality but have found a way to both reaffirm what you are calling the vulnerability of others.  But also, it isn't enough to be fellow victims of a horror.  It requires hope.  It requires some source of hope.

And so I just want to lay that out for your reflection because part of the modern world has been a very materialized — I don't know how to say it exactly — a very material vision of what creation is.  We see the crack as almost a material crack as opposed to a disorder of spirit or meaning. 

And I wonder if in moving beyond religious traditions, moving beyond even the feeling of the recognition of what literature usually has supplied in its cultures into a realm of the new and the modern, we might have actually left behind some of the solution.

PROF. FRANK:  Well, a lot of people have said exactly that.  And again, this is a huge issue that you've put on the table.  I really love your phrase, "no longer hiding from basic reality."  And rather as seductively enticing as it would be for me to trot out my favorite philosophers of modernity and the ways in which they've responded to your expanded version of this crack, actually I was trying to discipline myself today and stay away from the expanded vision to a somewhat narrower vision because I guess my own tendency is to go exactly where you're going and see the more expanded issue, and we can talk about ways in which an enterprise like sociology is really a secularization of what was previously a theological vision and trying to handle the same problems.  So I agree with you exactly.  I'm just a little reluctant to go there.

Where I would like to go from what you've said are the comments you made about your own training and the way you felt.  The University of Calgary has a good medical school.  I know a lot of the people who teach there.  Some of the people who teach there are also people who care for me as physicians, and I know they're really good.

When I asked my medical students to take a look at the draft of my 13-step program — and they were very kind in helping me refine various things — one of the things that was fascinating was how many of these points, all of which I take to be pretty obvious, they said, "Nobody has ever said that to us.  Nobody has ever raised that issue."  I mean, the need that I hear reflected in the things that you've said, very moving things about your own training, why isn't there someone there raising these issues in medical schools?

The most contested thing that I see in the medical schools that I visit is time.  They're just constantly having curriculum fights over very small units of time and who gets an extra hour lecture block and all of these things and, you know, if they want to introduce something new, it's like the priests of Nemi.  Someone has to be killed off so that someone else can get, you know, their lecture slot fitted in for their kind of thing.  And these are not handled in generous ways.  They're handled in quite Machiavellian ways very often.

Why aren't these students getting the kind of — well, I'll use the contemporary word "mentoring" — but that's a more secularized word than I really mean.  Why aren't they getting the mentoring, counseling, advice from our more senior people, what our first nation's people would call "elders," helping them adjust to this divide that you've described so well, because it is overwhelming.

One of the most interesting subgroups of medical students are those who become seriously ill either during medical school or they enter medical school having already gone through an experience of serious illness.  And if you attend to their voices, you can learn a great deal.  They generally feel quite alienated, quite marginalized.  The medical school doesn't have any particular vehicle for taking their experiences onboard and treating them as privileged witnesses again or, in an anthropological sense, privileged informants.      That really says a lot about what's missing in medical schools nowadays. 

So I think the value I would take from your reflections are what's missing and, without getting to the kind of usual curriculum wars, how do we find ways to make this available to these students, because there is advice from elders that can certainly ease this.

On one level, everyone just has to confront these things him or herself and there are ways in which that's just going to be a rough passage for some people.  There are also ways in which having someone guiding you, the proper companion, can make an enormous difference.

CHAIRMAN PELLEGRINO:  Thank you very much.  Dr. McHugh?

DR. McHUGH:  Dr. Frank, I very much enjoyed your talk and want to emphasize before I ask another question what I most appreciated about it.

First of all, I appreciated the historical setting in which you pointed out the transition from physicians in the '50s to now with the advance of technology, the intensive care units, the things of that sort that make our capacity so much greater for the care of patients, for the treatment of their diseases, and at the same time so much more expensive and, therefore, costing us in various ways in our professional aims, purposes, and often feeling abused in the process by the managers of those technologies and those institutions that provide these things.

It is said, by the way, though as usual, that the problems of today are due to the solutions of yesterday.  I can tell you that certainly in this case, it is true.  What we could do before the intensive care unit came with all of its equipment and the discoveries of medications and technologies it made possible, I remember very well, and I now see and am, in fact, the product of that kind of care that has extended my life even, as I understand, more of the demands that were put on the doctors and the nurses in that process.  So I very much appreciated that vision that you brought to us.

The second thing I very much appreciated was, in your discussions here and even very much in your 13 points that you are emphasizing, that we should be self-questioning people in the process as professionals.  The greatest and most thoughtful people in any profession, but particularly in medicine, should be people who are questioning themselves and questioning their processes as they work at what they're doing.  And in that way, by self-questioning, they can improve, not only themselves, but also the organizations that they're in.  I very much appreciated those points that you're making and would align myself with a lot of what you're saying.

But I have to say that there's a problem really for someone.  Perhaps it's because I was educated in the '50s, and there may have been at that time a posture of development that was different.  I don't really think it is radically different, but it might have been a different cast in the context of that time.

But at that time what was very clear was that one of the things expected of us as doctors that are not mentioned here would be that we were going to be taking risks, even risks at great cost to oneself, to become a successful and quality and real physician and that these risks were deep and important.

In fact, if I can tell a little story — you believe in stories.  I believe in stories up to a point.  They persuade and seduce as well as to inform, but here's a little story.

When I was graduating from medical school, the leading physicians in the departments of medicine in the three Boston hospitals came to talk to us about why we should go to the Brigham, to the BI, to the Mass General, the Boston City Hospital.  But the only one I remember was Dr. Herman Blumgard, the head of medicine at the Beth Israel Hospital, and he got up before us all bright and shining physicians-to-be and he said, "Well, if you come to the Beth Israel, I have something to offer you.  It's called poverty, chastity, and obedience.  And out of that process though, you will become an excellent physician of the kind that you wanted to be."

It was a direct challenge in this way, and I'm trying to voice it in this way, to this beginning of what you said, which was that in the contemporary era when you talk to young physicians, or young medical students anyway, that what they're looking for is balanced lives.  And I submit to you that that is a non-risk-taking position that, if you can't at the age of 25 or 26 be willing to say, "I'm going to venture out and see what happens and do what I can for the benefit of my patients, and I hope I'll get a balanced life ultimately and I hope I will have something meaningful to show," I'm not sure that you can be anything ultimately but a cynic in the long run, that ultimately you need to have the capacity to say, "I'm going to give it my all," and in that way have what I believe is the ultimate aim of this development, by the way, often developed by example and not necessarily being taught in the form of ethics by example in which the aim and purpose of the education was to develop an integrity of your desires that will justify other people to trust you.

And that does mean sometimes having an unbalanced evening or two.  And it's that that I want to ask you, Dr. Frank.  Where is the risk-taking here in the process of, as I would want for you and for me, to be generous?  But "generous" now means generous at the level of the blood and bone.

PROF. FRANK:  It's a very eloquent statement of a professional ideal, and who wouldn't want someone who expresses that, who embodies that, as you've said it?

There's a level at which what happens is not going to be decided by you or by me or by the Council.  Life will go on, and forces will shape what happens and, in my view, contingencies will enter in that we can't imagine, and these young people will become who they become in institutions that require them to become that sort of person.  And whatever either of us would like, it will happen.

The issue is — as I was reading this, I was struck again at how I was perpetually dividing things into two through my whole talk.  It's the most binary-oppositional talk I've ever put together, and I think the reason for that is when I try to think seriously about these issues it always involves a balance.  It always involves, well, there's this side, but then there's this side.  And both sides of that balance have their demands.  Both sides have some legitimacy behind them.

You've spoken very eloquently about the physician who takes risks including his or her own life.  First of all, these young people often do do that.  They go to third-world countries.  They've often got into medical school on the basis of having taken years off doing work that was dirty work in different places.  They're highly committed.

By the same token, what I hear in this notion of balanced life — and it's a researchable question.  We could all hear different things depending on who we're tuned into.  But what I hear is a recognition that the old heroic image is really no longer attainable and it always had its downside.  The downside was the physician-as-god syndrome.  The downside was medical paternalism.  It was a lot of things that instigated bioethics back in the 1960s.  You know, it's what got people like Paul Ramsey and Jay Katz and others to realize that there was a necessary counterbalance that had to be brought in because medicine was somewhat out of control, and we're here today in response to the, I think, quite correct perception that there was excesses of physicians who were not risking with their own lives.  They were sometimes risking with other people's lives and not getting the fullest consent for the risk they were taking with other people's lives.

And so there's the heroic side and there's the dark side, and if physicians today want balance, it's not just that they want to have their own evenings with their families.  It's also that I think they are looking back on certain excesses of the past, and they're seeking to avoid those.

And, unfortunately, what you said is entirely true.  Every present age is a solution to the past age and it tends to throw out often some of the finest aspects of the past age in an attempt to remedy some of the excesses of that age.  And to that extent, we're all on the wheel of history, and we try to hold on to what is best.  Sometimes we're successful.  Sometimes it gets lost for a while and has to be brought back at a future period.

What I've tried to do is the smallest way in which I can think about people recognizing the deforming influences of the institutions in which they work and holding onto the best impulses which I think were part of the challenge that was being presented to you.

It's such an ironic thing to have Beth Israel quoting the Catholic monastic tradition, but that's an example of being able to reach across and take whatever was best from the past and hold onto it, and that's what we need to do.

CHAIRMAN PELLEGRINO:  Professor Schneider, this will have to be the last comment.  We've used up our time.  Carl?

PROF. SCHNEIDER:  In the interest of having the trains run on time, I'm happy to yield back my time.

CHAIRMAN PELLEGRINO:  You don't have to.  You do have the floor if you wish it.

PROF. SCHNEIDER:  I'm going to get it pretty soon, so I'll wait.  Thanks. 

CHAIRMAN PELLEGRINO:  Thank you.  We will reassemble at 10:30.

CHAIRMAN PELLEGRINO:  Good Thank you very much.  Those of you who are here, thank you.  I think we'll move ahead.  The next session is a continuation of the discussion of the healing professions/medicine.  We're going to be addressed by Professor John Hardt, Loyola University of Chicago.

Dr. Hardt, the floor is yours.

PROF. HARDT:  Thank you, Dr. Pellegrino.  Dr. Pellegrino reminded me at the break of the Council's custom of not doing extensive introductions and rehearsing lists of publications and honors, and that's a custom for which I'm tremendously grateful.  Given a review of my CV, it admits of no other kind of introduction than a brief one.  So it would be difficult to tell you what a privilege it is to have this invitation to be here today and I am truly grateful, and I hope that my comments can be of some help to you as a deliberate body.

I've read with interest the Council's transcripts from previous meetings during which you've discussed what has been described as the "Crisis in the Ethics and Profession of Medicine." Many of your previous distinguished guests have attended to the negative affect of market forces on the medical profession and the need for a morally enriched system of medical education to counteract that influence and bolster society's and the practitioners' perception of the profession.

My comments today steer a course at some distance from those concerns, although I am coming to think that these two topics — that is, market influences in healthcare and my topic today, conscience and its relation to the moral foundations of medicine — may very well be related in the end.

This morning, I hope to build upon Dr.  Pellegrino's closing comments from your meeting of September 6 in which he recognized something of an identity crisis in medicine today.  He suggested that we ought to attend to the current confusion concerning the profession's understanding of its own relationship to society, a confusion that Dr.  Pellegrino suggested might be resolved, at least in part, by what he called a "reprofessionalization," a kind of reestablishment of the moral foundations of medicine that would undergird the traits that characterize "professionalism" — as he described them: competence, fidelity, and trust — with a normative moral vision of the profession itself.

I think that the recent debates concerning conscience in the clinical encounter are an important expression of this confusion about medicine's relationship to society noted by Dr. Pellegrino.  I say this because I wonder if the question of conscience's role is, at its core, a question about how medicine, individually embodied in the physician, relates to society, individually embodied in the patient.

The two articles I supplied to the Council offer you some perspective on the issue of conscience in the clinical encounter and the recent attention it's been receiving, and I'm happy to return to those as you see fit in question and answer.

But my comments today are aimed at arriving at a simple conclusion that I think can be stated in two parts.  First, much of the current and contentious debate over the role of physician conscience in the clinical encounter rests upon an under-attended-to but longstanding dialogue about the nature of the physician-patient relationship and, more broadly I think, what constitutes the appropriate ends of medicine.  To the extent that we fail to see this, I worry that our debates about conscience in the clinical encounter will generate more heat than light, leaving us as a society more polarized and angry with one another than reasoned and willing to civilly engage each other as we search for some common ground.

Second, if we as a society — or the profession itself, as some have proposed — simply ban conscience from the clinical encounter or even prohibit persons of serious religious and moral commitments from becoming physicians, I am worried that we will cut short a much needed conversation about the ends of medicine and the future course of medicine as a social trust and a professional practice as these issues, I think, lie beneath our concerns about conscience.

To help anchor this very theoretical claim, I'd like to consider the following case:  Mr. John Burke is a 54-year-old widow[er] of three years, the father of three daughters, a professor of marketing, and a patient of Dr. Robert McMahon now for the past four years.  He comes to the office today for his annual physical.  His exam confirms what Dr. McMahon suspected upon Mr. Burke's presentation; namely, that Mr. Burke is a healthy man. 

"Everything looks good, Jack," concludes Dr. McMahon, with a pat on the back as Mr. Burke rights himself on the exam table.  "You've even lost four pounds since I saw you last. You're doing great."  Reaching for his pad to write a prescription for a persistent allergy, he adds with characteristic warmth, "I wish more of my patients were like you."

Mr. Burke smiles, slides his arm into the sleeve of his shirt and begins buttoning, reluctant to interrupt the physician's pen on pad with his question.  "Glad to hear it, Doc.  I — there is — uh — there's one more thing I want to talk to you about."

Dr. McMahon leans against the exam room counter, rests his hands in his pockets and faces Jack, offering his full attention.  "Of course, Jack.  What's on your mind?"  "I've begun dating again."  "That's superb news, Jack!  I'm thrilled for you.  While we haven't discussed it much, I can imagine how difficult Angela's death has been on you and the girls.  I'm so pleased to hear that there's an opportunity for some personal happiness in your life. You deserve it."

"Thanks, Doc.  She's a wonderful woman.  We've been seeing each other for four months now and things are going well.  But I'm having some problems with impotence — you know, ED, erectile dysfunction."

"Oh, okay.  Sure.  Fill me in a little bit."

Less than a minute into Mr. Burke's recounting of his experiences in the past month, Dr. McMahon mercifully relieves him of his narrative, saying, "Jack, this certainly sounds like what you think it is, and it's not at all uncommon.  Know that there is nothing more serious going on here.  You're healthy and have nothing to worry about.  And as you probably already know, there are some options for medications out there that treat ED very successfully."

"Well, great.  I mean, good then.  I'm happy to hear that it's nothing serious.  This isn't the easiest thing to talk about."  "Please don't be embarrassed, Jack.  I appreciate your trust and candor."          "So which one of these medications would you recommend," asks Mr. Burke. 

A pause precedes Dr. McMahon's answer as he takes a seat on his stool.  "Jack, this is awkward for me, but I can't prescribe any of these medications for you."  "What do you mean?  Am I not a good candidate for these drugs?"  "No, you certainly are.  You're just the kind of person these pharmaceutical companies would want to reach," replies Dr. McMahon. 

"The problem is that I'm not the right doctor for you on this.  What I mean is that, as a point of principle, I don't prescribe these drugs for men outside of a marriage.  I don't mean to put you in an uncomfortable position here, Jack.  And again, I really appreciate your willingness to talk to me about this.  It's just something that I feel committed to in my pract—"  "Are you serious Doc?  I mean, are you able to refuse this?  But you're my doctor!"

This case scenario above recounting a physician's claim to conscience in the clinical encounter is, in the minds of many, cause for alarm. When presenting this case to healthcare professionals, the responses I hear are predictable and often visceral.  Many respondents share a common sense that this physician has in one way or another failed to fulfill the obligations of his professional role.  I've heard the following and repeatedly:  this physician has imposed his personal values on a patient, embarrassed a patient, damaged the physician-patient relationship, betrayed the patient's trust, violated the patient's autonomy, and degraded the practice of medicine by failing to meet the public's expectation of what happens in a doctor's office.

However, when the dynamic of the case slightly changes, opinions invariably follow.  So, let's say, for example, that Mr. Burke is not a widow but a married man who reports the same problem with ED.  In response to Dr. McMahon, saying, "Oh, I'm so sorry to hear that.  It must be putting a strain on your marriage," Mr. Burke replies, "Oh no, Doc.  Angela and I have not been intimate with each other in over a year.  I'm having this problem with the woman I'm having an affair with.  She's much younger than me, and it's really embarrassing."  In this instance, many in the audience become uneasy prescribing the medication.  I would suggest that this change is worth paying attention to.  And I think that its significance can be revealed by thinking about the questions this case poses to our understanding of the physician-patient relationship and the ends of medicine.

The claim that Dr. McMahon has in some way violated the physician-patient relationship is telling insofar as it reveals an opinion about what that relationship should be; namely, one in which the physician is a competent, technical expert whose role is circumscribed to "providing factual, relevant information and implementing the patient's selected intervention."  I've borrowed this language directly from the Emanuel's benchmark article, "Four Models of the Physician-Patient Relationship," in which they describe the "Informative Model" of that relationship.  It's also been described as the "consumer" or "provider" model of the physician-patient relationship, one that stresses patient autonomy and the physician's role as a technician who restores or improves a particular capacity, system or function at the patient's request.

But were we to wholly adopt such a model of the physician-patient relationship, we'd be left in something of a bind when considering this same case with its subsequent alteration.  Here, a model of the physician as technical expert, one whom assumes a stance of absolute moral neutrality, prevents the physician from a consideration of the moral seriousness of the act he's being asked to contribute to; namely, the patient's infidelity in his marriage. And, for many, this is untenable because it forces one into living a morally fragmented life.

So, in part at least, the debate about conscience raises questions about the moral life in general and the relationship between one's sense of self as a person and the various roles one embodies over the course of a day and a lifetime.  I will only briefly suggest here that it seems as though a coherent understanding of the moral life requires that one carry fundamental moral commitments across role-specific boundaries, and the work of Alasdair MacIntyre and others have argued this eloquently.

While one's moral commitments may be shaped and even constrained by the role one embodies — and this is particularly important for consideration of the clinical encounter — I don't think that they can be wholly abandoned if we are to consider ourselves as good people rather than good role performers.  I should remain fundamentally the same person, the same moral agent in the roles I embody as professor, father, husband, friend, and school-board member.

But here, we encounter another issue that informs a consideration both of the physician-patient relationship and the moral foundations of medicine. The idea that our actions actually shape our moral character thus influencing who we become — an insight whose roots go at least as far back as the ancient Greeks — is increasingly distant from our contemporary sense of ethics as it pertains to medicine, one predominantly shaped by a prioritization of personal autonomy over relationships and virtue. 

There seems to be a growing chasm between our moral autonomy, our moral acts, and their effects on others and ourselves.  Thus, the very idea of moral cooperation, the notion that participating or contributing to an action of another that one deems immoral is of serious moral concern, gains little traction in the contemporary debate.

This, too, then poses a challenge to physician conscience in the clinical encounter.  In fact, when a physician refuses a particular intervention based on conscience, it is often looked upon as an act of selfishness or even aggression toward the patient. Some have suggested that physician conscience is nothing more than a weapon wielded in our culture wars, one that runs counter to the conception of the physician-patient relationship that preferences patient autonomy as the determinant both of the good to be obtained in the clinical encounter and the sole source of moral authority in the physician-patient relationship. While physicians could misuse the clinical encounter in this way, they do not necessarily do so when considering their consciences.

It seems to me that the formative force of human actions upon their agents is of particular importance to medicine insofar as the skill-set and body of knowledge physicians acquire allows them to engage, influence, restore, and enhance human capacities that are frequently laden with moral significance.  This is obviously true in areas of reproduction, embodiment, and sexuality — and painfully true when physician expertise touches upon the deepest of human experiences:  finitude, illness, loss, and death.

While cultural mores may have shifted away from the reverence that has at times adhered to these arenas of human experience, for some they have not. And, when we consider the case of Mr. Burke, the fact that much of the audience shifts its opinion when it becomes a question of participating in the patient's marital infidelity indicates to me that there remains something to the sense that our bodies do convey moral meaning and that we as persons are shaped by our actions. It is no accident, then, that conscience is a live issue for medicine, a practical art that bears upon the human body.

How we come to a shared conception of the physician-patient relationship is an arduous and not necessarily clear path, but I am certain that this is a critical component in understanding the debate about conscience and the future of the profession.  If the profession of medicine prohibits physicians from thinking of themselves as moral agents, inherent difficulties will present themselves to us as we try to chart a course for morally reinvigorating the profession.  While conscience poses many difficult problems to us, prohibiting its presence in the clinic is not a preferable answer in my opinion.

There is much more to say about conscience, but let me just offer a quick three observations before briefly moving on to the ends of medicine.  Many arguments against conscience dismiss it as a uniquely private and religious claim and, therefore, undeserving of a place in the professional encounter between physician and patient.  While I don't find arguments that dismiss religious positions outright particularly convincing, it is worth noting that insofar as conscience is the faculty of mind that determines the goodness of an action, whether secular or religious in origin, all acts that are finally determined by a moral judgment are acts of conscience.  It is only those acts of conscience that run counter to contemporary mores or a widely accepted way of proceeding that get our attention.

But in the realm of medicine, we ought not to confuse the notion of an authentic, professional duty with what has become a customary way of proceeding, the latter of which one may actually have a duty to diverge from if that customary way of proceeding is judged to be immoral.  And, here, we face a challenge that touches upon the ends of medicine.  Medicine has customarily come to be perceived as offering services and interventions that some suggest simply are not within the purview of medicine.  It is on these kinds of cases that conscience usually arises.

Second, conflicts of conscience are part and parcel of living in a morally plural world.  We cannot voice support for moral pluralism while not expecting that people will actually hold to firm moral commitments that will, from time to time, conflict with another's firm moral commitments.  Thus, I think the way forward is not to try to eliminate such conflicts — the objective of banning conscience from the clinical encounter — but rather to carefully consider how best to accommodate and resolve these conflicts.  It's important to remember that patients can have positions of conscience too, and when they conflict with that of the physician, we should seek to identify a way forward that does not compromise the moral agency of either physician or patient. 

The "professional" physician in my estimation will be one who can simultaneously consider the divergent values appearing in the clinical encounter, carefully consider the variety of goods at stake and the ways in which the context of the physician-patient relationship form them, and, then, prudentially determines in dialogue with the patient a way of proceeding that promotes and protects the agency of physician and patient.

Third, some have suggested that conscience will become a bastion for bigotry, idiosyncrasy and personal bias, offering something of a personal asylum to accommodate a dereliction of duty on the part of the physician.  While I do understand this concern, I would not anticipate this outcome.  The ends of medicine are largely shaped by the physician-patient encounter — the experience of illness of the patient, the promise to help made by the physician, and the skill set that the physician bears in aiming toward the health of the patient.

So the profession of medicine does not readily tolerate the physician who refuses to care for someone based on gender or race, for example.  That constitutes a failure of duty in a way qualitatively different from the kinds of cases where conscience arises.

Second, conscience remains accountable to reason.  Positions of conscience are open to public and professional scrutiny and need to fit within a comprehensible moral framework.  When a conscientious objection in healthcare receive public attention, it is on those cases that exist at the margins of medicine.  Now there exists a long-running debate as to whether the ends-of-medicine are socially constructed and shaped by cultural expectation or internal to the practice of medicine shaped by the experience of illness itself.

Drs. Pellegrino and Kass have been two of the leading contributors to that debate.  There is little point in my rehearsing their arguments when they could do so more clearly.  But let me just suggest that if, indeed, the ends of medicine are purely socially constructed — and I don't think they are — but if they were, then our conception of the physician-patient relationship may very well meet and do little more than meet the minimal requirements established by the conception of the physician as technician who offers a service to the consumer.

The debate about conscience in the clinical encounter offers evidence that there is indeed disagreement about what the profession of medicine requires of the physician.  I want to suggest that the recognition of physician conscience in the clinical encounter is necessary in order to recognize the physician as a moral agent engaged in a practice that is morally significant, not only because of the merciful and altruistic underpinnings of caring for the sick, but because the body itself conveys moral meaning. 

Those who argue that conscience does not belong in the clinical encounter ultimately do so based on an argument from patient autonomy.  The abuses of paternalism that led to the dominance of autonomy are well documented, as is the swinging of the pendulum toward patient autonomy as its corrective.  It is also well-documented that, in large part, the principle of autonomy recognized and protected the patient's prerogative to refuse overly-aggressive medical treatments.  Now patient autonomy has increasingly come to include demands for services, services that pose a difficult challenge to the profession of medicine insofar as their provision requires either the technical expertise of the physician or the power of the prescription pad.

Thus, there is something of an internal conflict within medicine as it is the gatekeeper of resources and skills, some of which its practitioners may not be comfortable using toward a body of goods that reach beyond medicine's response to illness and disease.  And, on this point, there is a burgeoning body of literature that examines the relationship between biotechnology and medicine, asking the question as to whether medicine should go beyond the treatment of disease and toward the satisfaction of various human desires that fall within reach of biotechnology. 

Theologian Gerald McKenny has observed, for example, that medicine has become "a primary discourse on the good."  Given that, one can ask whether we are narrowing our conception of the good life to one wholly shaped by a particular vision of biological flourishing at the cost of other human goods.

Some, indeed, have suggested that the prevention of conflicts of conscience in the clinical encounter — and a recovery of the moral foundations of medicine — would require a shared conception of medicine that fit within a broader understanding of human health and flourishing.  This amounts to the establishment of something of a robust moral anthropology.  Here, one would at least have a common construct for ranking the various goods and obligations that medicine would serve and fulfill. But even here one can imagine disagreement and uncertainty as to how to rank various goods and interventions even within a shared system.

In any case, given the morally plural culture in which we reside, such a shared vision remains somewhat illusive, which brings us back to the clinical encounter where divergent visions will meet — and for which we ought to carefully consider how to proceed.

Given that, I want to close with just a few observations about how conscience might appropriately enter the clinical encounter.  Conscience requires one to employ their moral agency wisely and in a manner that fits the context of the interactions in which it arises.  Conscience is not blind to context. Rather, it is informed by it.  As I mentioned earlier, the fundamental moral commitments of conscience that one brings from role to role are certainly shaped and constrained by the particular role one embodies. 

So, for medicine, I think we have to particularly attend to the power differential between physician and patient. It is critically important to preserve the patient's dignity, to avoid embarrassing the patient, to try to fully understand the patient's good from the patient's perspective, and to consider the other goods at stake when one considers drawing upon conscience as a decisive force in the clinical encounter.

These protections for one's patient, it seems to me, are part and parcel of being a physician and congregate under the promise to "do no harm."  In many of these cases, a physician's conscience will dictate that the physician ought to meet the request of the patient before her, despite the fact that, all things being equal, the physician may wish the patient would choose otherwise.  But this, too, is a decision of conscience.  Thus, conscience is not always an answer in the negative.  But once again, it is the refusal that garners public attention.

Being context-contingent, conscience is sensitive to the various goods at stake in the clinical encounter.  So, for example, Dr. McMahon who is reluctant to prescribe Viagra to Mr. Burke ought also to consider the good of this particular relationship, the possibility that his refusal to prescribe this medication could permanently fracture that relationship and perhaps negatively influence Mr. Burke's future health, the possibility that refusal to subscribe Viagra in this circumstance may contribute, by word of mouth, to other patient's fears and concerns about visiting a doctor at all.

The consideration of these contextual factors also indicates that the physician should consider both the moral gravity of the action he or she would be participating in when making such a determination — all acts are not morally equal.  Proponents of conscience need to weigh against the false notion that one can obtain a kind of perfect, moral purity that simply does not exist in this life. 

While each of us, physicians included, has an obligation to follow our respective consciences, we have also an obligation to not hide from the reality and various contingencies of our lives.  There are other practical issues to discuss around questions of conscience.  If the Council so chooses, I'm happy to do so.  The problem posed by geographical scarcity, a possible duty to inform or refer patients for procedures and interventions, and the idea of preserving the social good of making legal medications available are all issues that remain on the table. 

But I'm going to stop here, having tried to suggest why it is that conscience is both a symptom of the identity question posed by Dr. Pellegrino and, possibly, part of the solution as society and the profession of medicine continue to deliberate the right way forward.

I welcome your comments, correction, and questions, and thank you again for the opportunity. 

CHAIRMAN PELLEGRINO:  Thank you very much, Prof. Hardt.  We've asked Professor Carl Schneider to open the discussion.  Carl?

PROF. SCHNEIDER:  Maybe I can begin with something that I think relates in some ways to this and relates as well to what Prof. Frank talked about.  It's part of my continuing program to suggest that there is no such thing as a new bioethical problem.

Prof. Frank talked about the problem of there being a morally successful professional.  In 1886, Justice Holmes spoke to the graduating class at Harvard about why it was a good thing to be a lawyer and concluded this way.  "And now, perhaps I ought to have done.  But I know that some spirit of fire will feel that his main question has not been answered.  He will ask, what is all this to my soul?  What have you said to show that I can reach my own spiritual possibilities through such a door as this?  How can the laborious study of the dry and technical system, the greedy watch for clients and practice of shopkeepers' arts, the mannerless conflicts over often sordid interests, make out a life?  Gentlemen, I admit at once that these questions are not futile, that they have often seemed to me unanswerable.  And yet I believe that there is an answer.  They are the same questions that meet you in any form of practical life.  If a man has the soul of Sancho Panza, the world to him will be Sancho Panza's world; but if he has the soul of an idealist, he will make — I do not say find — his world ideal.  Of course, the law is not the place for the artist or the poet.  The law is the calling of thinkers.  But to those who believe with me that not the least godlike of man's activities is the large survey of causes, that to know is not less than to feel, I say — and I say no longer with any doubt — that a man may live greatly in the law as well as elsewhere; that there as well as elsewhere his thought may find its unity in an infinite perspective; that there as well as elsewhere he may wreak himself upon life, may drink the bitter cup of heroism, may wear his heart out after the unattainable."

That leads me to the way I want to try to begin the discussion of this exceptionally interesting, lucid, thoughtful, and stimulating paper.  All I want to do is talk a little bit about a parallel kind of problem in my own profession of the law.

We've been thinking about this problem for a really long time because, much more than doctors, lawyers identify themselves with clients and make the clients' interests their own.  One of the most famous articles on the ethical role of the lawyer is an article that describes the lawyer as a friend, a friend who almost completely identifies himself with his client and the client's interests.  And the practical sociology and psychology of law make that kind of identification almost inevitable.

Now, the trouble with that, of course, is that when you begin to take somebody's interest as your own, you are going to be involving yourself in enterprises that you don't always like very much.  And, of course, if you were something like a criminal lawyer, you will be involving yourself in activities that nobody will like and you will know perfectly well that sometimes you will be working to get someone who should be in jail out of jail, that you will be freeing somebody to go out and do more horrible things.

The problem, of course, is that even if you say, "Well, I'm not going to be a criminal lawyer.  I'm going to be another kind of lawyer," you wrap yourself and your client together and then find that your client is doing something that you cannot approve of.  The trouble is that you are then so morally implicated in the relationship with your client, the client has become so reliant on you, that it's very difficult to know what the right thing to do is.

Suppose, for example, that you are a lawyer representing someone in a divorce and you have been helping this person almost as a counselor in a very full sense.  The person then announces a desire to have custody of the children, and you have excellent reason to believe that the client would be a very poor custodian of the children; in fact, perhaps even a dangerous custodian of the children.  What do you do?  If you're a lawyer representing people who want to form a company, what do you do when you begin to suspect that they are engaged in unethical, fraudulent, criminal activity?  Do you go to the police and say, "Here's my client with whom I have become so involved.  He looks like a pretty guilty person to me.  Pack him off to jail for me"?

So the easy answer is, you're never obliged to represent anybody.  But even that easy answer turns out not to be very easy on inspection because there is a professional and generally social belief that people are entitled to representation, that people will benefit from representation.

Maybe the answer is that once you become the counselor that you are entitled to give counsel of a moral kind, and, in fact, the code of ethics specifically says, if you think your client is doing something unethical or immoral or illegal or fattening, you should say so.  And the question, of course, then becomes, what do you do when your client says, "Well, that's your opinion"?

That's a good place to stop, so let me stop.

CHAIRMAN PELLEGRINO:  Thank you very much, Carl.  Prof. Hardt?

PROF. HARDT:  So it's a very difficult and good question, so let me just take a stab and it, and I don't know that this is necessarily right.

It seems to me that one of the differences between law and medicine is that the legal system depends upon attorneys passionately and aggressively aligning themselves with their clients' interests.  Medicine, it seems to me, require physicians to passionately and aggressively align themselves with the restoration of health, which is a shared goal with the patient but isn't necessarily the same as the patient's interests.  Now frequently, it will be.  And there will also be some negotiation going around about what constitutes the goal of this particular encounter.  So the physician may be saying, "No.  You know, let's treat this pneumonia caused by the vent," and the patient might be saying, "Enough is enough.  I've been dealing with this condition for a decade.  I'm an old woman now.  The goal of health is not worth the burden it's imposing on me to continuing to persist this way."  So there would be negotiation around that common goal of health, but I don't think that there's that same allegiance to the patient's interest that a physician has in the physician-patient relationship.

And I'll stop there, unless I didn't at all address your question.

CHAIRMAN PELLEGRINO:  Dr. Carson?

DR. CARSON:  Thank you for that very thoughtful discussion.  I thought it was spectacular, and I can't imagine how any reasonable person could believe that you can extract conscience from a physician-patient relationship even though some might proclaim to have done so.

At the risk of throwing out an analogy — and I say a "risk" because usually when you throw out an analogy everybody starts trying to figure out ways to break it down instead of figuring out what you're saying. 

But, you know, suppose you were a gun dealer and a man who lives in the wilderness comes to you and he wants a gun and he wants it because there are wild bears and they attack people.  Well, you're probably going to want to advise him on the best type of weapon to protect himself and his family in that situation.  However, if he wants it because there are criminals in the area, even though you may be quite willing to sell him a gun, you might have some other advice for him in terms of how to deal with that as opposed to shooting the criminal.  If he wants it because there are certain types of people, perhaps from across the border, that he just doesn't like and he wants to kill them, then you really are going to have think seriously about whether you're going to sell him any type of gun.  And I think that would probably be a universal feeling about people.

Well, I think physicians are very much in the same situation.  There are some situations where everyone would unanimously agree that you simply can't go along with that program and others in which you can.  But, you know, I think that the real key here is, one has to say, what is a real physician?  What is a healthcare provider?  You are there primarily to make sure you do not compromise that patient's health and that you enhance it.  But you must also make sure that you don't compromise your integrity because then your effectiveness as a caregiver is going to be significantly impaired by your guilt.

PROF. HARDT:  Nicely said.

CHAIRMAN PELLEGRINO:  That's to the point.  Thank you.  Anyone else?  Dr. Dresser?

PROF. DRESSER:  Thank you.  I thought that was a very balanced presentation.  I wonder if you think that the vulnerability of the patient creates any kind of a presumption in this area.  And then, second, what about perhaps an educational organizational approach that would address these issues more ahead of time?

So, for example, in the '80s, we had some physicians saying, "Oh, I'm not going to operate on patients with HIV because I don't want to take the risk of being infected.  That would be unethical because I have responsibilities to my family."  And medical residents starting complaining that they were taking care of too many HIV patients and they weren't getting the kind of education they should.  So some schools started putting in the catalog to med students, "Part of what you do will be caring for patients with HIV."

I wonder if more could be done in that area.  For example, I mean, if you're thinking about going into critical-care medicine or geriatrics and you're someone who thinks one should never forego life-sustaining treatment, is that a realistic belief to have, a permissible belief to have, to go into those areas or should you go into a different area?  So I wonder if you've thought about those kinds of systemic, I suppose, ways to, not eliminate conflicts, but reduce the conflicts?

PROF. HARDT:  Thank you.  That's also a very good question and a difficult one. 

I suppose that I have a couple of concerns.  One would be, I don't want us to find ourselves in a position where, for example, if you're going to be an OB/GYN you have to agree to participate in abortion or you have to agree to refer all of your patients for preimplantation genetic diagnosis or prenatal testing to make sure that they don't give birth to a child with Down's Syndrome.  And that is the concern, that what we'll do is say, "Well, if you're this type of physician, then you shouldn't practice in Arena X." 

Now your case about geriatrics, let's say, and aggressive life-sustaining measures is an interesting one because that becomes a moral question, and I do ethics consultation in our hospital, and that's one that we come up against quite frequently where you'll find either a family member or a physician who thinks that participation in this particular act of removing the vent, for example, would be immoral, would be directly causing the death of the patient.  Those are authentic and serious moral considerations, but I think that's of a different kind than saying, if you're opposed to Procedure X, then you shouldn't be this kind of doctor.

Now that said, you can't be a surgeon, if you're opposed to scalpels.  So that goes to us kind of identifying the internal nature of the ends of medicine.  There are some things that you simply can't be opposed to if you're going to be a physician.  But what I would want to suggest is that in these arenas of conscience, we are pushing at those margins, at those interventions, those drugs, etcetera, that don't easily fit within a particular end.  A followup?

PROF. DRESSER:  Just a brief followup.  I wonder what you think about duty to inform of options versus offer the procedure or whatever.  Is there a difference there?

PROF. HARDT:  Sure.  I'd be happy to comment on that.  Let me say one thing before that because originally I thought your question was going to be, do physicians have the obligation to warn patients before they enter the clinic that, "By the way, I'm this kind of doc.  I don't prescribe or do A, B, C, and D"?  I'd be in favor of that especially because of the power differential that you mentioned.  I think it would be better to let patients opt out of that encounter and conversation to prevent embarrassment if they want to before they find themselves in it.  So it would have been better if Dr. McMahon had posted in his waiting room, had handed out with the insurance form a form saying, "This is the kind of practice I hold to."  That's one issue.

Regarding your followup here about referring versus informing of options  — and this is somewhat off-the-cuff.  I haven't completely thought through all of these issues — I think one could make an argument that a physician has an obligation to inform a patient of all options that are socially considered part of medicine today even though some of those options the physician, one, might not consider part of the ends of medicine, and, two, might be strongly morally opposed to.  But I think that you really compromise a patient's moral agency if you don't give them the options that are out there whether you judge them to be morally good or morally bad.

The second comment I would make is that, on referring, here one gets deeper into this issue of moral cooperation, and I'm reluctant to say that a physician has an obligation to refer, particularly for services that the physician might consider gravely immoral.  Abortion comes to mind.  If you are of the opinion that this is a human life that's instilled with the full moral value of personhood, then your writing that referral brings you fairly close to that act.  Certainly many people would say that.  So I'm much more reluctant there.

But laying out the options for a patient?  I think there's room for that.

CHAIRMAN PELLEGRINO:  Prof. George?

DR. GEORGE:  Well, thank you, Dr. Hardt, for that great presentation.  You have a real teacher's gift.  I envy your students at the University of Chicago.  They're very fortunate.

PROF. HARDT:  Thank you.  I'm at Loyola University.

DR. GEORGE:  Loyola.  Well, then, I envy them.  I have two questions.  Let me ask the first one and then invite you to respond, and then if I could ask the second one, I would appreciate it.

My first one is whether the conflict or difference of opinion in the profession is really between those who hold the conception of the physician or healthcare provider as a technician and those who have a different and broader view that would make more room for conscience?  Is that really the division?  And you can tell by my asking the question I suspect it isn't.  Or is it simply a difference of opinion on the substantive moral questions? 

Here's my guess.  My guess is that there are a relatively small number of people in the professions who hold the technician view.  They may think they do.  They actually don't.  And when you press them — and you've already taken one step with Dr. McMahon in radicalizing the problem when you shift to infidelity.  We could easily wipe out anybody, virtually eliminate from the room anybody who would be unsympathetic to Dr. McMahon simply by further radicalizing the hypothetical case.

So I'm wondering, is the real difference just the substantive moral differences on questions like sexuality and abortion and life and death and so forth?  And then, if that's the case, then it becomes a struggle within the profession as to whose moral vision is going to prevail in the practice of medicine and the health professions more broadly.  And, of course, medicine itself can't answer that question internally and so it begins to look like a political question.  Is what I suspect true?

PROF. HARDT:  I think that it is.  Thank you for the kind words, and I think that your comment is right on point.  So there is another issue underlying this idea of the physician as a competent technician, and what I suspect is that when you read arguments or hear arguments that argue against conscience in the clinical encounter and may suggest that the physician's obligation may be shaped by what's legal and what the patient wants, which is essentially a description of the physician as a competent technician, that really isn't necessarily what they mean.

The issue is that that group is very comfortable from a position of conscience with the way ethics is proceeding and with the way medicine is proceeding.  The ethic that's informing medicine fits their moral vision of the world, so they don't have any hang-ups about the way we're going forward.  So it's easy for them to say, "No.  Let's just make it what's legal and what the patient wants and make it our guide."  But I do think that each of us has our hypothetical case where we would say, "Well, wait.  I don't know that I wanted to go in that direction."  So while some folks may not have a problem with the way we're practicing now, I imagine there are those cases and those instances where they would have that problem.

To the second part of your question, so does this just become a battle of moral visions within the world of medicine and are we going to get that critical mass of Physician A versus Physician B to tilt our vision of medicine in one way or another?

Here, I think I would defer to folks like Dr. Pellegrino and Dr. Kass who have suggested that, no, there are actually ends of medicine that are revealed to us independent of one's political leanings and that adhere around the notion of illness and health that we understand fairly commonly, and that's not to say that there wouldn't be room for debate within that, but that the experience of illness itself and the response of medicine gives us a set of fairly defined ends that constitute the practice of medicine and that remain somewhat independent of any particular vision or system.

DR. GEORGE:  Thank you.  My second question has to do with entry into the medical profession in particular, though for all I know it might be applicable if it's an issue at all to other parts of the healthcare profession and I frankly hope it's not an issue and that you can assure me that it's not an issue.  I raise it in the following context.

Recently, Dr. Pellegrino, Dr. Hurlbut, and I were among some speakers at a conference at a small Catholic university in Ohio called the Franciscan University of Steubenville, and it was on healthcare ethics.  And at one of the panels, I was startled by the focus of the audience in asking questions, and these were mostly Catholic, but not exclusively Catholic, doctors and nurses and other healthcare professionals and their focus on what they perceived or asserted as being barriers to entry into medicine against those who have traditional religious beliefs or moral convictions or both. 

Evidently — and I'm myself from a legal background, not a medical one — but evidently medical school, unlike law school, sometimes involves interviews for admission, and various members of the audience, one after another, began talking about interviews that they had experienced or that they knew about in which the prospective students were being asked questions which seemed to be trying to smoke out their religious and moral convictions in a way that they've thought must mask an intention to ensure that people who think perhaps the way that Dr. McMahon thinks, you know, won't be allowed in the profession because they won't be able to fulfill what those in power currently think doctors ought to be doing.

So this is the first I've ever heard of this particular problem, if it's a problem at all, and I'm wondering if, from your perspective, there is a problem and, if there's not a problem, what would be causing this particular group of people to think there is?

PROF. HARDT:  So I can speak to this with really no authority at all.  You know, I teach at a Catholic medical school.  I can tell you that I have a colleague who sits on the admissions committee.  We welcome students of all divergent backgrounds, religious and nonreligious alike.  But we're certainly welcoming of people with religious commitments as we think it contributes a great deal to the catholicity of our institution, which is something we care about.

Could there be the formation of kind of a subtle moral litmus test to the profession of medicine?  I suppose that's possible.  I've never heard of it myself.  Now I'm fairly new to medical education, so people senior to me may have more stories of this.

And as to what would account for these people's experiences, I mean, I would give them the benefit of the doubt that what they say is true, although without seeing that interaction, it would be very difficult to judge what was being detected.  I wish I could give you a better answer than that, but I don't think I can.

CHAIRMAN PELLEGRINO:  Further comment?  Bill — Dr. Hurlbut?

DR. HURLBUT:  I'm not exactly sure what my question is, but it's something about what Robby was saying and also about what you're saying about conscience and the way medicine today is kind of a referendum on the good.

When we did our report, "Beyond Therapy," we found it fairly hard to make a clear distinction between enhancement and therapy, although we recognize that the vast majority of medicine is clearly therapy, but increasingly there's this edge.

But it seemed when we surveyed these various edges and their potential extensions that it had something to do with this wider, larger comprehension of what you call the good or what's life's purpose.  And it's caused me to think quite a bit about the historical relationship transculturally of the priest and the healer and how medicine has somewhat to its benefit and somewhat to its detriment moved into a separate quadrant, and yet it seems there will increasingly be divisions about this.

I mean, obviously a great deal of it flows from the fact, if you will, of our pluralism, the convergence and encounter of peoples from all over the world with a lot of cultural traditions that differ and significantly on, not just matters of spirituality, but their actual medical practice rooted in matters of spirituality.  But I guess what I'm trying to get at here is the question of whether there is such a thing as a sort of spiritually-neutral medicine. 

I was thinking, by the way, as you were speaking, the first mistake that — was it Dr. McMahon?  Was that the name of —

PROF. HARDT:  Yes.

DR. HURLBUT:  Dr. McMahon, the first mistake he made, I think, was to interrupt his patient a minute into the description.  He could have at least listened and let that man play out the justifications that would have followed, if my experience with patients is right.

And what I mean by that is there is still a prevailing ethos in our culture even though we're diverse.  For most people, they're very conscious of what other people think, not just what they think themselves.  So that what may have followed is he would have started to explain to the doctor why he was in this intimate relationship.  He might have said something like, "Well, I'm violating my own ideals of not being in a relationship before marriage, but I'm so lonely," or "I'm confused."  Slowly, other goods may have come out into the equation.  Now whether that would have changed the doctor's opinion or not — but that's a vague question.  I think you know where I'm going on that.

Speaking to the relationship between — I thought one of the best things you said, by the way, was the imperfection, even it would run against the ideal.  Now we in medicine deal all the time with patients who are behaving imperfectly.  I mean, the whole realm of sexuality is full of that.  I mean, we wouldn't turn people away because they came in with either bad practices or diseases that resulted from those.      And obviously it's very true of a whole range of human behaviors, not the least of which is the evident overeating in this civilization and so forth.

And it strikes me that there's a connection between what the first speaker said and what you're saying that relates down to that vulnerability issue, that medicine encounters a lot, the inability of the patient even to do himself, him- or herself, what he knows is right.

I'll just add one little element to that.  It does strike me that this is a place at which the physician has a special opportunity to both be compassionate and still uphold moral principle.  And, well, it's a vague question, but talk into it.

PROF. HARDT:  Okay.  Thanks very much for the opportunity.  So morality and compassion should not be polar opposites.  I think those two things can go together.  And I do wonder sometimes if allowing conscience in the clinical encounter is not allowing humanity in the clinical encounter.  But there is something to be said for a physician being able to reveal herself as the person she is, the things she worries about, the things she cares about.

I don't want to turn the clinical encounter into a personal counseling session with your pastor though.  So I do think there are boundaries there.  I don't want physicians proselytizing.  I don't want physicians guilting.  And I think that all of those things are contrary to the ends of medicine.  They fall into that admonition to do no harm.

But what I rely on then is a really prudential physician.  I need a physician who is wise and careful and discerning.  And how do we get those future physicians into medical school?  I don't have a good answer for that.  But as the speaker before said, a lot of this is about developing people with character.  That's one of the things I took from Prof. Frank's comments.

Let me just try to touch on a couple of the themes, and if I forget something, please tell me.  You said, "I don't know that there is a religiously- or spiritually-neutral medicine out there," and you talked about the relation of the physician and the priest.  I would agree with you on that insofar as I tried to indicate in my comments.  Medicine touches on profoundly deep human issues, as deep as they come.  You who are physicians touch upon them.  So I want you to come to that with a wisdom and appreciation of how rich and deep those goods are that you're involved in. 

But it's also the case — and someone correct my medical history if I get this wrong — that part of what Hippocrates was about was setting himself aside from the priests and the witchcraft that was going on and say, "No.  We are something different here," and kind of narrowing the parameters and narrowing the approach and the duties and obligations to set oneself off from that so that we don't overly blur that boundary between priest and physician.  So as is the case in most things, this is an issue of balancing, I suppose.

Tell me what else you mentioned there that I missed.

DR. HURLBUT:  Well, you've certainly hit on some very central things.  Let me make a comment on what you said.  I mentioned my earlier medical training.  I'll do it a little more here.  I noticed within two weeks of my starting medical school — they did arrange early clinical encounters for us and so forth and sometimes just privately interviewing patients — and I noticed very quickly that patients were actually going through something that I imagined was like confession for them, that I was actually being asked by the patient implicitly to be more than a physician would traditionally be.  And it struck me right away that this was part of the result of the secularization of society, that there was not this other ancillary social, not service, but you know what I mean, social provision for patient's personal spiritual needs and that physicians were asked to take up the slack in that.  So, well — I don't know.

PROF. HARDT:  So I'll comment on that if you don't mind.  That makes good sense to me, that the clinical encounter now becomes this intimate realm because this is one person in your life that maybe in the past there were more than that who you had almost an obligation to be forthright and honest with, disclosing of yourself and your failures and shortcomings and that they were going to engage you on matters of incredible significance in your life.

One of my concerns is when I do an ethics consult on a case and I talk to the physician and I'm trying to get a sense of patient history, what his family said, what's at stake here, and they will very much concentrate on the medical and say, "We'll get a chaplain for that stuff," so that there is this sense that, you know, the human stuff, "We leave that to nurses.  We leave that to chaplains.  Let me talk about the medical, because that's what matters."

And to the extent that physicians have narrowed their vision that way, I think that, if they have, that's a tremendous shortcoming in professional development, and that's not to say I don't want nurses and chaplains.  I do, and they do a superb job.  But the idea that the physician doesn't have to worry himself or herself with those things strikes me as innately wrong and misguided.

So that points to the fact that, yes, a physician is a competent technical expert of the human body, granted, but the physician is more than that.  So it is something of an expanding definition I think we need of what it is to be a doctor today.

CHAIRMAN PELLEGRINO:  I would like to say a word, if I might.  As you all know, I am limiting my comments with the Council, but I'd like to respond to Robby's question, just some fact issues.  I was not at the session that Robby attended, so I didn't hear those questions, but I've heard them [from others] many times, and I'd like to simply... without further discussion ... [answer] them.

The question is asked.  I've been on the faculty of [several] medical schools in different parts of the country, and I've been on the admissions committee fo ... those schools at some time or another. I can assure you the question is asked.

The second issue was, does it have an effect on admission?  That's very difficult to discern.  Those of you who have sat on those committees realize that there is a committee discussion.  The members of the committee are all human beings with their biases, prejudices, values, etcetera, and it's hard to know how the informa