Jay Fiedel, this is you from the North. Today we're asking how does Canadian immigration and immigration policy differ from that of the U.S.? And what can the U.S. learn from how Canada does it? And we've discussed this with Dr. Ken Rogers, retired Canadian businessman in Kelowna, British Columbia. Welcome to the show, Ken. Hello, Jay. This is a subject where Canada is very different than the U.S. Well, that's better because the U.S. ain't so good. The U.S. has needed immigration reform for decades and decades. A friend of mine worked in Congress on immigration reform, and he wrote so many bills that never even got considered over a lifetime. So, you know, what happens now is it deteriorates further. So my first question to you, is, Ken, to explore the differences, you know, have any migrants come to Canada from Latin America and from Africa, from Europe, from Ukraine? Do you have the same kind of border situation that we do, the same kind of policy issues that we do about migrants and immigration? Well, in theory, we have, you know, many of the same problems, but a lot of them, they're just at different degrees.   Now, where the U.S., the Mexican border is a very major problem. That's the whole issue in the United States. Nobody cares about, you know, Canadians moving into the U.S., but they certainly care about the southern border. Well, your immigration in the U.S. is a big political subject. And yet, it's as if the subject was because the sheer quantity of immigration. Well, that's just not correct if you compare it with Canada, or let's just say Canada has a population that's about 11% of what the population of the U.S. is. But we have about one-third as many new immigrants into Canada each year as the U.S. does. You know, that is, we have one and a quarter million new immigrants into Canada. But the basis of the immigration is very different. The cornerstone of the U.S. immigration policy is what I call family reunification. You know, where in Canada, the family reunification amounts to about the same number of immigrants per capita relative to Canada. But most of our family reunification is where someone comes to Canada on a temporary permit to be a college student. When they have a college degree in Canada, they, you know, are attractive for Canadian jobs. And so, the family reunification then comes to a great extent because you've got some educated person bringing some of their family members. Well, the definition of family reunification in Canada is not as broad as in the U.S.  You know, it's got to be pretty direct family. Where the cornerstone in Canadian immigration is all economic based. You know, we have 12 times as many immigrants proportionally as the U.S. does on economic grounds. You know, our economy, for example, in the recent five-year period that they had some statistics, 80% of the labor force growth in Canada came from immigrants, you know, from the direct immigration. And Canada has a point system for, you know, who's better for the Canadian economy than the next person. You know, what are we short of? Now, we use two temporary immigration programs very heavily. Let's say about two-thirds of the immigrants that come into Canada each year are on a temporary basis. And virtually all of those are students or temporary workers. You know, and you get a special temporary work permit. For example, where I live, it's a very major agricultural area in terms of orchards, orchards and wine growing. And we have just tons of Mexicans come on temporary work permits. But if they've worked here for, you know, each season for two or three years, some of them even get to work year round, then, you know, they become attractive new residents. You know, like they, you know, can move from the temporary status to a full-time status. And so you really have a pretty smooth way of doing it. Similarly with the colleges, you know, Canada stands on their head in particular to get graduate students. And that they will, when somebody's got their college degree, then they obviously would be attractive to Canadian industry for jobs. And so they join the labor force and then they may bring their family members. Now, one of the big differences with Canada and the U.S. is we don't have a Mexican border. We did recently have a bit of a Mexican problem, as we had so many Mexican workers that had come here on a temporary basis that eventually became citizens, that it became, you know, evident to a Mexican that Canada wasn't really all snow and ice. There were some really nice places to live in Canada that even a Mexican could enjoy. And so they started to have, you know, because of all the tourist flights from Canada to Mexico, you know, there's some pretty cheap airline flights sometimes of the year.  And they actually had a change, just a very recent change was that, you know, we used to have Mexicans could come to Canada without a visa. You know, the same as Americans don't need a visa to come to Canada. And they just, you know, change that back to requiring Mexicans to have visas to avoid that miniscule problem in terms of quantity.  So the U.S. Southern border, you're sitting where, as I understand the statistics, nearly 50% of the people that show up at the border get rejected. You know, well, Canada doesn't have a big rejection rate because how do you get here to be rejected?  Why not? It seems to me that if I'm trying to get into the United States from the Southern border and the United States is theoretically attractive, you know, they hear nice stories from relatives and friends who live here. So they try to cross over and have a better life. But, you know, Canada is a rule of law country. It's a country with opportunity. In many ways, it's a country with a government that cares more about you than in the U.S. or at least the Republicans care less about you. But, you know, why doesn't somebody who's coming in from Latin America say, gee, I'm not going to fool around in the U.S. Southern border. It's too much trouble and risk. Bob Weyer, what have you, political machinations. Why don't I just go to Canada? I'll find a way to go to Canada. I'll beg, borrow, steal the money for that airplane and I'll wind up in Canada and I'll be happy there. I mean, I feel that's an opportunity waiting to happen for a lot of people from Latin America. Why isn't it happening? Well, the Latin America needs the money for the airplane flight, you know, and, you know, those people that arrive on an asylum basis would be, you know, sorted out the same as in the U.S. and probably the same percentage would be rejected.  One of the odd items in Canada, because one of our provinces Quebec speaks French or at least the, you know, the official language is French, but about a third of the province primary language is English, mainly in Montreal. But, people from Haiti that speak English, which had all of, you know, their horrendous problems and made it into the U.S. somehow or another, they actually, you know, went to New York State, upstate to the border between New York State and Quebec and were walking across the border there. And, you know, they, the place they famously gave it a name that every Canadian knew, Roxham Road was, because you could, when you arrived in New York City, you could actually hire a cab and drive you to that border. You know, they had regular service to get people to go to that border. And those were Latin Americans that, that preferred particularly anybody that spoke French, you know, that was their spot that they preferred to come. So, yeah, the odd, you know, Caribbean island other than Haiti, where there was French speaking, and that was the route that they've used. This raises the question of the quality and intensity of enforcement of the immigration laws regarding immigration, sanctuary, refugee status, all that. How well organized is the border patrol to the extent that it's like, you know, that Canada has a border patrol? How well, how much enforcement do you see? How much contention do you see? I mean, how much legal process do you see rejecting people who want to come across who really don't qualify? How much investigation is going on to find the people who don't qualify and, you know, identify them, maybe put them in jail, maybe send them back? What kind of process is going on? What do you see in the newspaper about that? Well, border patrol, when you watch TV and you see the American southern border, you know, border patrol tends to be agents in airplanes or vehicles monitoring the US-Mexican border for people trying to come across illegally. Well, the only border we've got is with the US, about 4,000 miles worth, and I don't think there's anybody that patrols. We have official border crossings, you know, where you drive up and, you know, there's a booth on the Canada side and a booth on the American side, and you got to, you know, when you're leaving Canada, you just, you don't even wave to the Canadian booth, and when you arrive at the American, you know, it takes very little time and click, click, and you can go into the US from Canada and vice versa.  I mean, if you could somehow arrive in Canada, you know, without going through a border station, you could be here for a long time, and nobody would give a hoot unless, you know, you need a work permit, you know, like a social insurance number or the equivalent driver's license, those kinds of things, you know, eventually those, you know, would have you registered somehow somewhere, but generally, we just don't have a problem with undocumented residents. So, you don't have immigration agents running around doing raids on businesses and arresting people and foster raiding them, and then deporting them, you don't have that? No. What about the ocean? Actually, I know of one example, just show you how extreme this one is. A lady that I knew reasonably well was a flight attendant for a Middle East airline, and, you know, they suddenly decided that they weren't going to pay any benefits or something, and they could hire staff that, you know, were cheaper than these people. She was from Britain. Well, she had parents that lived in Canada who became ill, and so when she left this airline, she came as a caregiver, and she just came in by an airplane and, you know, showed her British passport and so on, and you're here to, you know, as if it was like a visit, you know, but she decided to care for her parents. Well, eventually, both parents died, and 15 years later, she applied for some government aid, and they said, well, how come you're here?  And this is the only case I know of, of anybody, you know, in that sense, where I had any personal connection with anybody that had any role. So interesting. What about, what about the oceans, you know? I mean, we have a lot of, for example, we have a lot of drugs that are moving into the United States through, through the coasts, through the ocean. Why, why can't you talk about these sort of stations along the 4,000 mile border? But why can't I just get in a boat and come from somewhere in the Caribbean, or come from somewhere in the U.S., you know? I mean, as an illegal U.S. immigrant, and take a boat through Nova Scotia, I mean, in the summertime, Ken, in the summertime. And enter Canada that way. I mean, is there any action to find me, to exclude me, to arrest me, to enforce the immigration laws against people who come in by odd means that way? Well, we do have a Coast Guard, but it's really not much.  And, you know, their equipment is pretty old, so that if your boat was fairly new and fast moving, you could get around them anyhow. But in order to get to, to a port in Canada, you either have to come across the Arctic Ocean, or you have to come past the U.S. You know, like if you have an ocean crossing craft, you, you have enough money, you don't need to come to Canada illegally, you could easily get to Canada or the U.S. on some other logical basis. You know, it's, it's really asylum seekers that are trying to walk across a border and, and you just can't walk across very easily in Canada. So, you know, we just don't have the problem with the illegal immigration, but one of the, the key points is just the sheer quantity of immigration. Like the United States, if you listen to the news, one of the favorite phrases in the U.S. is, we are a country of immigrants. Well, you're sure not a country of immigrants compared to Canada.  And we let in 1.2 million immigrants.  You know, give them a five-year click and, and at least 80% of those temps convert into permanent immigrants, permanent citizens. And similarly, in the United States, about 15% of the U.S. population was born outside the United States. Well, nearly 25% of Canadians were born outside Canada. I mean, it's just a huge difference. Well, you know, this reflects the public opinion of Canadians, and certainly of Canadian officials, about, about allowing immigrants to come into the country. You know, it reminds me of Singapore, where Singapore will say, hey, we need, we need a million people to staff various businesses. So we're going to open the floodgates. We're going to take in a million people. They're going to give them whatever visas are appropriate. We're going to give them jobs. We'll place them and we'll give them homes and we'll let them buy the homes, usually apartments in these high rises. And that, that way we make sure that our economy is staffed by, you know, the necessary number of people, namely immigrants. And I suspect that that's kind of the public policy in Canada, where, you know, the officials over years and many administrations have said, we want extra people, more people. So we'll open the floodgates, we'll be really liberal about letting people in, letting diverse groups of people in. We're not opposed to that. We'll encourage that, you know, we'll structure it, we'll manage it, but we're going to take a lot more people. This is not an accident that you have so many people coming in relative to the U.S. So what's your sense of the public opinion and public policy that underlies all of that? Well, before COVID, there was never anybody grumbled about immigration in Canada, where before COVID, that was always one of the top subjects in the U.S. political era of just what stinks about American policy and immigration was pretty high on lots of people's list, despite the fact that immigration, as a proportion of the population or the sheer size of it just didn't compare at all to Canada, you know, as Canadians that have, how could you possibly complain about immigration? It's a great thing.  In the U.S., it's about one and three, or one and three quarters, you know, still less than two, which you need to maintain the population.  You know, the immigrants provide a lot of things that are really important. You know, one of the factors that are, you know, jobs that other people don't wish to do, that's a main thing like, you know, all of the agriculture in California and Florida, immigrants work in the hot weather very well compared to a typical American or typical Canadian.  So, you know, we have, the Mexicans come and then they integrate into the economy and then the next wave of them come and it's all good. It's all good. So, you know, you mentioned, I think it's really important that the central difference in policy between the U.S. and Canada is that we have this kind of family connection system that allows people to come in and get visas and permanent residence on the basis of a family connection rather than an economic skill grade that's useful to the economy. Although I can tell you there are certain limited categories of people who demonstrate that they have some skill that's necessary and helpful. They can come in, but I don't think it's that many people. The bar is much higher than you would imagine. Okay. And so in Canada, they've got to demonstrate that they have some value to the economy. In my view, that's a really much better system. But what happens in the world of trouble? What happens when you have to consider groups of nationalities? If I'm, for example, potentially I could be a member of Hamas or Hezbollah or some other terrorist organization, am I being screened out? Am I being profiled as an Arab? You know, Trump, at one point, he was going to stop everybody from every Arab country. If you remember, I mean, people forget these things, but that's what happened when he first took office. And it was pretty gross because he was profiling hundreds of millions of people that way. But what does Canada do? Does Canada like this group and dislike that group? Does Canada have racial or ethnic or cultural divides when it allows people to come in, even for an economically valuable purpose? Well, we have always had, on the world scale, a fairly positive attitude towards asylum seekers. Now, of course, they can't show up on their own. They've got to have help getting there.  But they were mainly ones that helped the Canadian military force there. And, you know, even though we, in theory, would have them, we've still been pretty slow to do it. You know, a lot of Afghanis who assisted the Canadian military there actually, you know, had panicked and went left and went to Pakistan because Canada was so slow to get them here. You know, similarly, we had a ton of people from Vietnam near the end of the Vietnam War. You know, even though, you know, Canada didn't play a military role in Vietnam, we still, you know, had asylum seekers from there. We've had a ton of people from the Middle East.  So when you've got, you know, somebody with a passport that says they're coming from the United Arab Emirates, how was your border authority to know that they really came from Syria?  But we do get our share of people.  So we've got, you know, far from perfect. And it's only in the last two years that there really has been any major complaints by Canadians about immigration. And that's solely because of our housing crisis.  And part of the housing crisis was this, Canada was so open on these student visas, especially for graduate students, that some of these private universities, you know, call them Trump University type of scams, okay, it opened solely to, because foreigners could come in and apply for a university permit. And these were all set up almost as a way to get into Canada without really wanting to get a university degree or whatever. And so you had a ton of these universities where somebody had come and they would, you know, they'd get into Canada because they were a student and had the university papers. And then the college would then, you know, let them go for one course, let's say, and they would be able to get a, you know, a job somewhere. And so, you know, five years later, somebody finds out here's this person that only took one course the first year, or maybe they kept taking one course, you know, and five years later, they still have been finished their first year of college. You know, and that abuse, you know, is one of the items that without the housing crisis, nobody would have ever even followed up the chain to find out, how come we have this problem? How about the marriage abuse? You know, that has been, you know, a steady example of abuse in the country, in this country, where you marry somebody, and based on that marriage, you know, you get some kind of visa, maybe citizenship, because of the marriage. But the marriage isn't real. The marriage is a fraud marriage only for the purpose of getting immigration status. Do you have that? In other words, if I marry a Canadian citizen, will I get a visa? And if I marry that citizen without the intention of really being married, will I be caught and thrown out of the country? I would assume it happens here about the same as the U.S., and I would just assume that you wouldn't get caught about the same as in the U.S. It's not a big issue. Okay, well, you know, we must discuss one thing before we run out of time, and that's this, you know, it looks every day more and more like Trump could be the next president. And there are people, you know, who don't care, they don't realize what changes will take place, and there are other people who do care, as a philosophical matter, an ideological matter, and they worry a lot about their life and their quality of life changing.  So the question is, if they wanted to leave, you know, the number one possible country that's like the U.S., the number one place that has a rule of law and civil rights, you know, an economy that is similar to the U.S. Economist, a quality of life similar to the U.S., it would be Canada. But the question is, you know, how does the average American get to go there legally and get an immigrant visa legally? And then from that, get to be a citizen of Canada legally. How long does it take? That's a really big question. How long does it take? And what does that individual have to do to go through the process to get to be a Canadian? I remember during, you talked about Vietnam, I remember, you know, all these young people, they didn't want to serve in the army, so they went to Montreal. They didn't necessarily speak French either. They didn't just go to Montreal. We have a huge area of British Columbia that was just loaded with Americans who wanted to avoid the draft. You know, it's the area, it's in British Columbia called the Kootenays. It's just an absolutely gorgeous area. It's, it's, you know, right north of Idaho, like northern Idaho and western Montana are two of the most beautiful places in the United States like Glacier Park and that type of stuff, although they don't have glaciers anywhere at ground level.  And we have tons of those, but in terms of your question, the, it's easier to come from the United States to Canada than it is to come from almost any other country. You know, we started off in the British Commonwealth, so you could come from Britain or Australia or New Zealand, you know, pretty easily, but an American with a job and with economic talent would immediately be high on the points list. You know, Canada's jobs orientation or economic basis of immigration is, you know, you'd have a secondary factory be language. Well, Americans don't have a language problem, custom problem. Well, they'd say you've got to leave your gun behind. You know, that is, you know, on some basis, you know, if I were the agent, I might say I'd led an Australian in before I'd led an American in if I had to pick for two people with exactly the same qualifications, you know, just that minor difference in some social attitudes. However, the ability of somebody to an American to come to Canada on really short notice, you know, could easily be in Canada doing, working away if they were employable while their, you know, status is processed, you know, but the likelihood of a rejection is almost negligible if they've got a job. I mean, I remember growing up in Calgary, Alberta, and, you know, in, you know, when I started university, there was maybe 150,000 people in Calgary. You know, there's now a million and a half people in that city. It's more than a million and a half. I mean, very successful sparkly city, you know, much like Massachusetts, the, you know, very high standard living compared to everywhere else. Well, the high school I went to was about 50% Americans or sons of Americans who came to Alberta to work in the oil industry.  I forgot what it was called, but, you know, it was really the employer said, you know, we need this person and they've got qualifications that really suit our purposes and we are having trouble finding somebody else that can do that. And so, click and I get this three-year visa and then, you know, it was diddly squat to have it renewed and, you know, I was not at the time interested in applying for full-time citizenship, but that type of thing in reverse is readily available for any American with any skill. What about citizenship? Suppose I really like it in Canada and I don't feel like how could one not, I gotta interrupt say, how could one not like it in Canada?  However, sorry to interrupt you there. No, I just wonder what the track is to get from a, you know, a work visa, call it. I'm sure there are multiple possibilities, you know, categories of work visa, but from a work visa to a permanent resident, I'd rather, well, to a citizen. How many people in the high school, if you follow them, or in Calgary or, you know, in the cities of Canada that came from the U.S., ultimately became or become Canadian citizens? Well, a lot were dual citizens.  But there's lots of Canadians that moved to the U.S., worked there for a while, then moved back to Canada and vice versa. You know, one of my sons lives in Los Angeles. Canada has a certain kind of open door policy. And a lot of people, you know, are very appreciative of that. A lot of people came from Europe after World War II, and nobody would accept them, except Canada. Canada accepted them, and then ultimately they wended their way into the United States. But Canada was a tolerant, accepting place along the way. And it had a global reputation for that. Now you have complications in the world that you have described here. And I wonder where it's all going. Is Canada going to remain an open door country? Or perhaps is Canada going to start closing its doors? Are people going to react to events around the world and kind of shut the door, maybe on certain groups or in general? What are your thoughts about the future? Well, the Canadian government officially increased the number of immigrants they're allowing per year. You know, that's sort of measure one, where the U.S., the whole orientation of the Republican Party is to reduce the immigration, even though Canada has proportionally about three times as much immigration as the U.S. The racial tensions do arise in Canada. For example, there's a neighborhood in metropolitan Vancouver called Surrey. Or it's, you know, let's call it much like you'd say the Bronx is part of New York. Surrey is part of Vancouver. And there's about three quarters of a million people live in Surrey, but it's very, very heavily Punjabi. Or let's call it from the Sikhs, SIHK, however you say it's Sikh or Sikh, how it's said. And that there's a ton of gang wars that really came from the countries that those people came from, you know, where they want to fight each other and the violence is just un-Canadian. Like this one suburb of Vancouver has more crime than all the rest of the metro together, including the downtown. And so there's actions of people create disgruntled attitudes, you know, like my example a couple of minutes ago. The Canadians become disenchanted with the groups that are fighting among themselves.  You know, like, you know, the sympathy, there was no great problem before that. You think this is going to be a change in Canada, you know, sensitivity to things happening elsewhere and maybe disapproval of groups that are coming from elsewhere by association? Is the open door policy going to change? No. Okay, I just wanted to get your thought on that. We got to go. We're way over. So Ken Rogers, Dr. Ken Rogers retired businessman of a par excellence from Kelowna, British Columbia, helping us understand not only the immigration laws and policies of Canada, but how it works on the ground. Thank you so much, Ken. Aloha from Western Canada. Aloha.


Good afternoon. Good afternoon. It's a great pleasure to welcome all of you here this afternoon for a wonderful tradition at the University of Chicago, the annual Nora and Edward Ryerson Lecture. We, of course, have many lectures and many lecture series at the university, but this lecture, made possible by a bequest from trustee Edward L. Ryerson, Jr., is unusual in that the lecture is selected by a faculty committee based on nominations from faculty colleagues across the entire university. Now, being chosen as a speaker for this series is quite a remarkable statement. First of all, the faculty of this university is comprised of so many persons doing such remarkable work across a broad spectrum of intellectual pursuits that being singled out inevitably testifies us to the extraordinary importance of the speaker's work. But beyond their broad-based and deep achievements, the faculty of the University of Chicago are a group with unrelenting standards and uncompromising judgments. Thus, the Ryerson Lecture reflects the highest aspirations and standards of this most unusual community of scholars at the University of Chicago. This year's Ryerson Lecture is Dr. Mark Siegler, the Lindy Bergman Distinguished Service Professor in the Department of Medicine and the Director of the McLean Center for Clinical Medical Ethics. Dr. Siegler is a graduate of Princeton University and then received his MD in 1967 from the University of Chicago. He was intern, resident and chief resident in medicine at the University of Chicago Hospitals, followed by a year of advanced training at the Hammersmith, the Royal Postgraduate Hospital in London. Dr. Siegler pioneered the field of clinical medical ethics. In 1984, with the encouragement from then-University President, Hannah Gray, and support from the McLean family, he and his colleagues founded the McLean Center for Clinical Medical Ethics. The nation's first ethics program devoted primarily to clinical medical ethics. As an example of its early work in a 1989 paper entitled Ethics of Liver Transplantation with Living Donors, Dr. Siegler and his colleagues described their plans to perform the first such surgery, laying out all of the potential ethical issues four months before the first such case. Today, almost 25 years later, the McLean Center, of which Dr. Siegler is the director, remains the leading program in the world for teaching, study, and research in clinical ethics. The Center's faculty now numbers 25 and is drawn from disciplines and departments throughout the university. The McLean Center Clinical Fellowship Training Program in Clinical Ethics started in 1985 and is the largest and most successful ethics fellowship program in the world. More than 200 fellows have trained at the McLean Center, of whom 35 now direct ethics programs at other universities and hospitals throughout the world. The clinical ethics model developed here in Chicago has been widely embraced. Every medical school teaches courses in medical ethics. Every hospital is required to have ethical ethics policies and mechanisms in place to resolve clinical ethical disagreements. Scientific articles about medical ethics now appear regularly, not just in ethics journals, but in mainstream clinical and science journals. Dr. Siegler has held many lectureships and visiting professorships in the United States and abroad. He's been the recipient of more than 25 federal and foundation research grants. He's written or co-authored more than 150 journal articles, 50 book chapters, and five books. He's received many honors, including the Premio Cironi Prize by the Italian Medical Association and the University of Bologna, the oldest university medical school in Europe. He has practiced general medicine for more than 30 years and is one of the few physicians who combines expertise in medical ethics with an active medical practice. In addition to all of this, Mark has been a visible and important member of this university community and is widely respected and admired by so many of us as a colleague, university citizen, and as a friend. Dr. Siegler's topic today is at the Crossroads of Organ Transplantation and Medical Ethics A Century of Innovation at the University of Chicago. It is my great pleasure, both as president and personally, to give you the 2007 Ryerson Lecture. Dr. Mark Siegler. Bob and Therese, Jim Adara and Vicki, members of the Raney and Ryerson families, faculty colleagues, students, guests, and friends. I'm deeply honored to have been chosen by a faculty committee to present this year's Ryerson Lecture. Perhaps my strongest qualification for the honor is that beginning with Professor John Hope Franklins, an inaugural Ryerson Lecture here in 1974, and Professor Chandra Sekar's second lecture, I have attended 30 of the previous 33 lectures. My being selected shows if there ever was any doubt that attendance really does count. Since starting medical school here 44 years ago, it has been my great privilege to be a student and colleague of many former Ryerson Lectures. Today, as President Zimmer told you, I'll be speaking on the topic you see on the board. I have chosen to talk about organ transplantation and medical ethics for three primary reasons. First, beginning a century ago and continuing to the present time, physicians from the University of Chicago have made foundational contributions to the field of organ transplantation. Second, transplantation illuminates the incredible successes in medicine and surgery during the last century. The first successful kidney transplantation in 1954 was an extraordinary event. For the first time in human history, a person who was dying from failure of a critical organ, such as a kidney, liver, heart or lung, was saved from death by replacing the failing organ with a healthy one. Since 1954, more than one million organ transplantations have been performed worldwide. And finally, my third reason for focusing on organ transplantation is that we encounter every important ethical issue in medicine in organ transplantation. In poetic moments, I sometimes use the image that I show you here of the Rosetta Stone to suggest that organ transplantation can help us understand the complexities of medical ethics just as the Rosetta Stone helped us to understand and translate the mysteries of hieroglyphics. Essentially, if you understand the ethical issues in transplantation, you understand the major ethical issues in medicine. The idea of transplanting organs and limbs is not new. Throughout medical history, physicians and patients have sought ways to extend life or to improve the quality of life by transferring an organ or a limb from one person to another. This painting depicts two third-century physicians, Cosmus and Damien, performing innovative surgery by transplanting a leg obtained from a recently deceased person to a patient whose own leg was removed because of cancer. If you look very hard, you can see the removed leg on the floor in the forefront of the picture. This extraordinary scene was recorded in many Renaissance paintings. We are not told the outcome of the operation, but perhaps it can be surmised from the next slide of a painting by Fra Angelico. This scene, which shows the beheading of Cosmus and Damien, suggests that innovative transplantation surgery is a high-risk enterprise. Folks, please don't try it at home. Some regard Cosmus and Damien's fate as even worse than a malpractice suit. From the time of Cosmus and Damien in 300 A.D., there was very little progress on the transplantation scene for quite a while, actually about 1600 years, until the following statement was made. Can you see it in the back? The problem of organ transplantation in man has been solved. This remarkably optimistic statement was published in 1905, more than a century ago, by Dr. Alexis Carell, who was then working as an assistant to Professor Stewart at the Hull Biological Laboratory here at the University of Chicago. How can I say it, but this statement is so Chicago? Let me explain what Dr. Carell meant by this statement and consider whether it was true. In the 21 months from November of 1904 to August of 1906 that Carell was at the University of Chicago, his research achievements were astounding. During that time, he published 33 papers describing research breakthroughs that remain the basis of modern transplantation surgery. His breakthroughs included, first, the ability to sow blood vessels together. Second, the ability to reattach severed limbs. And third, the technical ability to transplant organs, including kidneys and hearts, into dogs and cats, mice and rats. This 1905 paper was Carell's earliest description of his transplantation work. And the article included the prophetic statement that I've extracted and show at the bottom of the slide, where he says, from a clinical standpoint, the transplantation of organs may become important and may open new fields in therapy and biology. For his work at the University of Chicago, Alexis Carell received the Nobel Prize in Medicine in 1912, as you see in the certificate, in recognition of his work on vascular suture and the transplantation of organs. Remarkably, Carell was the only physician or surgeon, I didn't know this when I started the talk, but was the only physician or surgeon between 1901, when the Nobel Prize was first awarded, and 1933, who received the Nobel Prize in Medicine for work done in the United States. Aside from Carell, Nobel Prizes in Medicine during the first 34 years of the Prize went exclusively for scientific work done in Europe. Carell was also just the second University of Chicago person to win the Nobel Prize after A.A. Mickelson took the Prize in Physics in 1907. We can now ask whether Carell's 1905 statement, which I show again, was true. The answer is it was not. Despite Carell's great technical achievements in 1905, scientists did not understand immunology. Most of Carell's animals died from immune rejection of the transplanted organs after several weeks or months. In fact, despite Carell's optimism, more than 40 years passed before a partially successful organ transplantation was done in man. And when it was done, you guessed it, it was done by a graduate of the University of Chicago Medical School, Dr. David Hume, class of 1943. The story of the first transplant goes like this, that while working as a surgical resident in Boston in 1947, David Hume was caring for a 29-year-old woman who was dying from acute renal failure. Hume decided to try to save her life by performing the first human kidney transplant. One evening, he obtained a kidney from an elderly patient who had just died during surgery. He and another resident wheeled the 29-year-old woman to a treatment room at the end of the hall. And using two gooseneck lamps for light, they attached the donor kidney to the woman's forearm so it rested outside the skin. They then covered the kidney with a plastic bag and watched as her urine drained into a jar. This primitive transplant lasted only four days, but that turned out to be long enough to allow the woman's own kidneys to recover, and she survived to be discharged. This was the first successful kidney transplant. In the years following this quite unusual case, Hume conducted the first series of more traditional kidney transplants and performed nine transplants using cadaver kidneys. Unfortunately, immune suppression drugs did not become available for another 10 years, and the longest survival among Hume's nine cases was 175 days. For his pioneering work, Dr. Hume is regarded today as the father of renal transplantation. Carell and Hume are two in a long line of great clinicians and scholars from the University of Chicago. The advancement of knowledge and intellectual innovation have been at the core of the university's mission since its founding. In an 1897 convocation speech, President William Rainey Harper expressed his hope that when the University of Chicago at last would open a medical school, it would be one committed to research and innovation. President Harper stated in the convocation address, quote, I do not have in mind an institution which shall devote itself merely to the education of a man who shall be an ordinary physician, but rather an institution whose aim it should be to push forward the boundaries of medical science, one in which honor and distinction will be found for those who make contributions to the cause of medical science, and one from which announcements may be sent from time to time so potent in their meaning as to stir the whole civilized world. I think back on my own medical school experience here and on my great teachers who contributed to the growth of knowledge and made amazing scientific discoveries. Leon Jacobson was the first physician to use chemotherapy. Charles Huggins won the Nobel Prize for establishing the relationship between hormones and cancer. Don Steiner discovered pro-insulin and revolutionized the fields of diabetes and endocrinology. Gene Goldwasser, my biochemistry teacher, isolated erythropoietin in 1977, a substance that is now used to treat anemia in more than 3 million people each year. And Janet Rowley, my teacher and colleague who presented the Ryerson in 1988, established the link between cancer and genetics. I also think of my clinical mentors who taught me to be a doctor and to care for patients. The incomparable Joe Kursner, who is in the audience today, Lou Cohen, Joe Barron, Al Tarloff, Arthur Rubinstein, and the late John Altman and George Block. These brilliant innovative scientists and clinicians at Chicago have changed medicine and medical practice nationally and internationally. They were my teachers and they remain my role models. This was the rich intellectual tradition that I experienced as a medical student and resident. I was honored to be invited to join the faculty in 1972. And then my very first assignment as a young faculty member changed my career path permanently. My chairman, Al Tarloff, asked me to establish and then direct the first medical intensive care unit in our hospital and one of the first such ICUs in the city. At that time, we didn't have very good ways to monitor patients. We didn't have particularly effective breathing machines to treat patients. And we didn't have doctors who specialized in intensive care as we do now, doctors who know what they are doing. Instead, we had enthusiastic amateurs, physicians like me, who suddenly found ourselves facing a range of clinical and ethical issues in the ICU for which we were neither trained nor prepared. I remember my residents and students asking me questions, peppering me with questions about whether we could ever stop a breathing machine after we had started using it or about how truthful should we be when we told families the prognosis of their loved ones. Or how we decided who got admitted to our ICU and whether we could ever move people out if sicker people came along later. These three issues, end of life concerns, truth telling, the rationing of beds. These were tough problems for which I could find no answers in medical journals or medical textbooks. My residents and I started to call this kind of practical, patient-centered work, clinical medical ethics, and that's how the field got started. At about this time, other worldwide developments in the transplant field made it imperative that we begin to address in a systematic way the clinical ethical issues associated with organ transplantation. Dr. Thomas Starzel had performed the first liver transplant in 1963 at the University of Colorado. Dr. Christian Barnard had performed the first heart transplant in 1967 in South Africa and the first brain death standards were developed in 1969. We realized then that clinical ethics was an important area for doctors and nurses and patients and I've spent my entire career working to develop this new field by teaching, by training fellows, by consulting for patients and hospital staff, and by doing research and writing. In 1984, as you heard from President Zimmer, we started the McLean Center for Clinical Medical Ethics at the University of Chicago and this work has been the center's mission for more than 20 years. In fact, I'd like to recognize and thank the center's benefactors and visionary advisors who are here today, Mary Ann and Barry McLean. Thank you. In our search for answers to the ethical problems we faced in caring for patients, I discovered that many of the intellectual leaders of the new American bioethics movement were on the University of Chicago faculty in the early 1970s. These ethic scholars were willing to teach me and help me to learn on the job a kind of apprentice system. My main teacher, you see on the left, was Jim Gustafson, university professor in the Divinity School with whom I met weekly beginning in 1972 to discuss real cases that I had seen in the ICU the previous week and that raised troubling and difficult ethical questions. Jim introduced me to Father Richard McCormick, one of the foremost Catholic moral theologians of the 20th century, who at that time was at the Jesuit School of Theology in Hyde Park and also to Stephen Tullman, a philosopher who joined the faculty in the Committee on Social Thought in 1973. Several years later, Leon Kass, another distinguished bioethicist and recently the chair of the President's Council on Bioethics joined the faculty. These mentoring relationships with these extraordinary scholars continued for the next 10 years. Jim Gustafson also introduced me to Ann Dudley Goldblatt, a brilliant teacher and legal analyst who has been a valued colleague and friend for more than 30 years. Clinical ethics aims to improve patient care and health outcomes. It does so by helping patients and families as well as doctors and nurses reach good clinical decisions, decisions based on both the medical facts of the situation as well as the patient's personal preferences and values. I have spent my career as a physician taking care of people. Nothing that I do gives me as much joy and satisfaction as providing good and conscientious care to my patients. I have also spent a great deal of time thinking and writing about the doctor-patient relationship. To my surprise, a paper I published in a somewhat obscure medical journal, the Bulletin of the New York Academy of Medicine, I don't think I've ever seen that journal since this paper, was discovered in 1982 by the President's Commission for the Study of Ethical Problems in Medicine. The commission was then rethinking the doctor-patient relationship in the United States. My paper had rejected the extreme versions of physician paternalism and patient autonomy and instead proposed a new model, the model of shared decision-making. The President's Commission accepted my view and concluded, quote now, in this report, the Commission encourages a relationship between patients and professionals characterized by mutual participation and by shared decision-making, end quote. And since then, shared decision-making has become the prevailing model of the doctor-patient relationship in the United States. While, of course, I would like to stand here and claim priority for proposing this new model, I hesitate to do so. Because, in fact, I was scooped, beaten to the punch, you might say, by Plato about 2400 years earlier. Plato clearly had shared decision-making in mind when he wrote his views about the doctor-patient relationship. In a remarkable passage in the Laws, to which Charles Gray directed my attention, thanks Charles for that, Plato contrasted good and bad doctor-patient relationships. In the bad relationship, and I'm quoting now, the physician never asks the patient for an account of his complaints. The physician prescribes treatments in the brusque fashion of a dictator and then rushes off in haste to the next patient. I know, I know, sounds a lot like managed care. By contrast, let me show you the good doctor-patient relationship. Here, Plato says, quote, the physician treats the patient by going at the things thoroughly from the beginning in a scientific way and takes the patient and family into confidence. The physician never treats until he has won the patient's trust and then aims to produce a complete restoration to health. Now this sounds very much like shared decision-making by stressing the importance of communication and trust and even agreement between the patient and the doctor. Now my discussion of shared decision-making and the doctor-patient relationship are just several examples of how clinical ethics contributes to improving patient care and health outcomes. In the past year alone, faculty at the center have published books on a wide range of ethics topics including Dr. Zlantos and Meadow, the upper left there, on neonatal bioethics, Dr. Mary Mahowald on bioethics and women, and Dr. Laney Ross on children in medical research. In fact, faculty member at the McLean Center have pursued a broad range of research during the last 20 years. I show some of the topics on this slide. Much of this work is interdisciplinary and relies on the great, unique opportunities at this university to involve faculty from many disciplines including public policy, law, the social sciences, and the humanities to focus on issues in medicine and the biological sciences. And now, as I promised in my title, I will turn to one of these topics. I showed at the bottom there transplantation ethics to try to illustrate how clinical ethics contributes to medical innovation and helps improve patient care. Physician ethicists at the McLean Center have worked closely with transplant surgeons now for more than 20 years to help solve the two central ethical challenges in transplant surgery. First, how to increase the supply of organs and second, how to distribute available organs in a fair and equitable way. I will begin by discussing two solutions to the problem of increasing the organ supply. One involving livers for children and the second involving kidneys for adults. Here's the pediatric liver story which President Zimmer mentioned some of the details about in his introduction. In the 1980s, liver transplantation had become very effective in saving lives. Unfortunately, because there were simply not enough small pediatric livers, 40% of infants and children with congenital liver disease were dying in the 1980s before they received a transplant. Dr. Christoph Brosch and his team solved this problem by developing a series of operations that culminated in a new operation that allowed living donors, usually the parents of the child, to donate segments of their own liver to their child. The living donor operation was quickly challenged on ethical grounds because the procedure was new and the risks to living donors were unknown. Would it be safe to remove a portion of a healthy person's liver? What would be the short and long-term consequences? One commentator asked, will this be the first operation with a 200% mortality? The general issue being raised by Brosch's critics involved the ethics of surgical innovation. Surgical innovation is not controlled by a regulatory process like that used for new drugs. As one observer put it, I show you here, there is no FDA for surgeons. Most surgical innovation is controlled not through formal review mechanisms but rather through professional and peer oversight. This is how most surgical progress has occurred in the past. For example, appendectomy, coronary bypass, heart valve surgery, minimally invasive laparoscopic surgery, and even organ transplantation. In working with Dr. Brosch and his team, our group of ethicists developed an approach to address the ethical problems in innovative surgery. The Chicago model emphasized these four elements. Establishing the clinical need for the innovation, assuring adequate scientific and clinical strength of the team, meticulously protecting the human subjects, especially the healthy donor who is just barely a patient. And fourth, announcing the plans for surgery publicly before the first operation was performed. On the matter of public disclosure, we did something, and President Zimmer mentioned this, that so far as we know had never been done before. We published this paper in the New England Journal months before the operation was performed. And we did it to alert the public and the transplant community to our plans and to invite responses and criticisms before we did the operation. The Chicago model for ethical surgical innovation has improved the process of professional self-regulation and has helped advance scientific knowledge while protecting patient rights and patient safety. Our clinical ethics work helped Brosch's program go forward initially in Chicago and later worldwide. The next slide shows the first recipient, Alisa Smith in 1990, with her mom, Terry, who was her donor. We also see Alisa at the time of her graduation from high school in May of 2006, a healthy and happy teenager. After Chicago published excellent results from its series of pediatric living donor transplants, many surgical programs in the U.S., Europe, and Asia began to perform the operation. Since 1989, living liver pediatric transplant has been done successfully in more than 30 countries and has saved the lives of more than 10,000 infants and children. In the U.S. and Europe, thanks to this new operation developed by Dr. Brosch and his team, mortality for children with congenital biliary atresia and needing a liver transplant has decreased from 40%, which it was in the 1980s, to less than 5% today. Now we also face an inadequate supply of kidneys for adults. This next slide, if you just focus on the extreme right-hand bars, 2006, shows that more than 100,000 people, this is the red bar, are on the waiting list for transplants and the yellow bar in 2006 shows that about 30,000 transplants were performed in that year.  This University of Chicago team, headed by Drs. Laney Ross and Dick Thistlethwaite and including Drs. Michelle Josephson and David Rubin, proposed a new model called the Paired Kidney Exchange Model to increase the supply of adult kidneys. Here is their proposal in schematic. Let's say that donor 1 wants to give a kidney to a relative, recipient 1, but there are biological barriers, like the wrong blood type, that do not allow for such a donation. Now let's say a similar problem exists for another pair of relatives, donor 2 and recipient 2, another biological incompatibility. What if donor 1 were a good donor for recipient 2 and donor 2 were a good donor for recipient 1? You could do a swap. This swap is what we called a Paired Kidney Exchange. Please note that donor 1 and recipient 2 are not related. Similarly, donor 2 and recipient 1 are not related. They don't even know each other. We predict that Paired Exchanges like these could greatly increase the supply of kidneys and not only that, but one way they could do it is by opening the possibility of a national or even an international registry for unrelated donors. Once you could do these in one pair or two pairs, you could do it in five pairs or you could do it in hundreds of pairs. Unfortunately, a major ethical obstacle has delayed the implementation of this novel idea. In the United States, only altruistic donations are currently permitted. A 1984 federal law prohibits the exchange of organs for, quote, valuable consideration. And the question quickly arose, does Paired Kidney Exchange violate federal law? Now Ross and Thyself Wade in the paper considered this issue, and in 1997 they wrote, I quote them now, in our view, the transplantation law was not designed to prohibit altruistic donations of organs by family members or close friends. Despite this 1997 statement, for the past 10 years, legal and ethical uncertainty has limited the widespread application of Paired Kidney Exchanges. I am delighted to report that this uncertainty is about to be resolved as of this month. In the past few weeks, the U.S. House and Senate unanimously, 420 to nothing in the House, unanimously passed legislation called the Norwood Living Organ Donation Act, which amends the 1984 National Organ Transplant Act specifically, specifically to allow Paired Exchange to go forward without risk of criminal or civil penalties. The President is expected to sign the Norwood bill quickly. Because the Paired Exchange program encouraged the use of living donors, who I showed you were unrelated to each other, many think that this proposal opened the door to a broader consideration of using market solutions to address the organ shortage problem. Two of our distinguished colleagues at the University, Professor Gary Becker and Professor Richard Epstein, have each written powerful and controversial papers proposing that the buying and selling of organs be legalized. Dr. Janet Rowley, who is a member of the President's Council on Bioethics, and Leon Cass has told me the same thing, they tell me that various market proposals are currently attracting an enormous discussion in Washington. I now turn to an example of distribution of organs fairly. I have to tell you in the next slide that the U.S. is divided into 63 organ procurement areas that generally represent states or large metropolitan areas. In the past, donated organs were kept within the same area in which they had been donated. From one area to another, however, there are often great disparities in the waiting time to receive a liver transplant. This slide illustrates the different waiting times by geographic area. I just want you to see that the shortest waiting times are in yellow, the longest waiting times are in orange, and you can see, as you glance at the map, that sometimes the orange and the yellow abut one another. They're adjacent so that some of the areas with the shortest and longest waiting times are actually in adjacent states. The ethical problem is whether the allocation of organs based primarily on geographic area results in the fairest distribution of scarce livers. My colleague, Dr. David Meltzer, conducted research for the Institute of Medicine that showed that in transplant areas with larger populations, donated livers were more likely to go to the sickest patients who really needed a liver to survive. By contrast, in less populous transplant areas, livers often went to people who could have waited two years or three years before they needed a transplant. Based on this research, Dr. Meltzer and the Institute of Medicine Committee recommended sharing livers across geographic regions and also recommended allocating livers based on the clinical need of the recipient rather than on geography or time on the waiting list. The official name for this new recommendation is the MELD system, model end-stage liver disease. I prefer to call the MELD system Meltzer's Equitable Liver Distribution. Several years of data have now accumulated and they suggest that the new MELD system is more equitable and more effective than the previous geographic system and is saving an additional 300 to 500 lives each year. My concluding example at the crossroads of organ transplant and clinical ethics relates to China and brings us very close to the present time. This exciting new work could potentially affect a quarter of the world's population. Our work with Chinese doctors and health policy leaders offers an unprecedented opportunity to apply the earlier ethics work at the University of Chicago to assist China in increasing its supply of organs for transplantation and to also assist them in obtaining the organs in an ethically acceptable way. The clinical problem in China is the dire, the dire scarcity of organs. I showed you that slide in which there were 100,000 people waiting for organs in America. China estimates that as many as a million and a half people currently need an organ, usually a liver transplant. The need in China is so great because of the high incidence of liver failure from Hepatitis B, which is endemic in China. Currently China performs only 10,000 transplants a year. Remember we performed about 30,000. China is the second country in volume after us, 10,000 transplants a year but it doesn't come close to meeting the need for one and a half million organs. But even with regard to the 10,000 transplants that are done in China each year there is also a major ethical problem and the ethical problem is this, that currently 95% of Chinese donor organs come from executed prisoners. This raises further ethical questions such as whether prisoners are being executed to get organs, whether condemned prisoners can really give voluntary informed consent the night before their execution and also should organs be sold to non-Chinese visitors, so called transplant tourism. Without doubt the Chinese organ transplantation system is under attack. China is accused by the Falun Gong of killing dissidents to use their organs in transplant. Globally China is reviled. Human rights violations such as using executed prisoners to obtain organs. Here are the three key players who are working to improve the organ transplant system in China. On the left you see Wang Zhifu, MD, the Chinese Vice Minister of Health and himself a distinguished liver transplant surgeon. In November 2006 at a national transplant meeting in Guangzhou China's President Hu Xintao appointed Dr. Wang to chair a new national transplantation committee charged with substantially changing China's transplant policies. Roy Schwartz on the right who is in the audience today is a distinguished physician and medical educator and former dean at the University of Colorado Medical School. Dr. Schwartz chairs the University of Chicago's Biological Sciences Division visiting committee. Dr. Schwartz is also the former president of the China Medical Board a philanthropic foundation in New York. In November 2006 the China Medical Board awarded a grant of one million dollars to the University of Chicago and to China naming Zhifu Wang and Mike Millis as the co-principal investigators. In the center is Mike Millis the chief of transplantation at the University of Chicago who was due to arrive back from China just two hours ago. Mike are you here? He was coming but he's not here yet. In March and April of this year Dr. Millis has been doing a Henry Kissinger imitation kind of shuttling between Chicago and Beijing twice this month and in March a Chinese delegation spent a week at the University of Chicago. Here are the clinical outcomes that China would like to achieve through this new partnership with the University of Chicago. First they want to improve the training of Chinese transplant surgeons. The first such course was held last week in Beijing. Second they would like to decrease the number of approved transplant programs in China. Third they would like to establish a national registry which no country currently has. And fourth they would like to develop a national system for organ sharing across regions. Those are the clinical outcomes. Now let me show you the ethical outcomes that China hopes to achieve through this new University of Chicago partnership. First China wants to join the world transplantation community by adhering to global ethics standards and plans to stop using executed prisoners as the source of organs. Two weeks ago the Supreme Court of China announced that it would review every death sentence in China before the sentence is carried out and most people believe that this decision is meant specifically to discourage using executed prisoners to obtain organs. Second China hopes to join most other advanced technological countries by establishing brain death standards. Third China will use the new brain death standard to greatly increase its supply of cadaveric organs. Fourth China will greatly expand the use of living donors. And finally China intends to prohibit the buying and selling of organs and to criminalize transplant tourism. I show you an extraordinary paper published this month in liver transplantation, the leading U.S. journal in the field. The paper is authored by Wang Jifu, the Vice Minister of Health and the Co-PI on the China-Chicago Grant. In this paper published this month, Dr. Wang announces China's goals over the next three years for achieving the clinical changes and the ethical changes that I have just described. In fact, two weeks ago the first changes were instituted when China decreased the number of approved transplant programs from 600 to approximately 100 and established its national transplant registry. My point in examining the China story at some length is to tell you what the University of Chicago and its clinical ethics group are doing in the world to improve not only transplantation practices but also to contribute to improving global human rights. Those of us working on the Chicago side of the China grant are not naive. It is not a done deal that the changes promised in China's transplantation policy will happen or that they will happen in the short timeframe we would like. But our collaboration with the leaders of Chinese medicine is a milestone. Vice Minister Wang's paper in liver transplantation was a public declaration of China's intent and we at the McLean Center and at the University are cautiously hopeful that good things will come from this partnership. You've heard today about a century of contributions by University of Chicago physicians and ethicists to the field of organ transplantation. Carell and Hume, Dr. Broch, Drs. Laney Ross and Dick Thistlethwaite, David Meltzer and our recent work partnering with China involving Jay Fu Wang, Roy Schwartz and Mike Millis. It has been our privilege at the McLean Center to work closely with colleagues at the University and with health professionals nationally and globally to improve ethical standards in organ transplantation. These improvements have helped to advance transplantation and have contributed to saving lives in this country and throughout the world. We know that we will see many more innovations in medicine and surgery in the next century as diseases that today are incurable yield their secrets and become curable. Isn't that one of the meanings of the University of Chicago motto? Crescat schientia vita excolatur. Professor Paul Shorry, who created this motto in 1910, translated it as follows, let knowledge grow from more to more and so be human life enriched. As a physician ethicist, I am proud that our group will continue working with basic and translational scientists to assure that we develop and apply new cures quickly and that we do so while adhering to the highest ethical standards of medicine. Thank you very much. I would love to entertain some questions. The lights are bright, so you may have to scream out so I can see you. I don't know if people in the back heard Dr. Rowley, but the question was about the terrible shortage that exists in America in organs and whether some kind of money or financial equivalent, like paying funeral expenses or providing health insurance or doing something, might increase the number of organs. Clearly, those who are in favor of the market system, I believe Richard Epstein may be and Richard's here, have written eloquently that there is no question in their minds that moving to a market system in organs could help meet supply and demand and could increase the supply by introducing some financial incentive. As Richard knows, I've been a little bit on the fence about this saying that it's a very dangerous experiment to try because of a phenomenon that Richard has written about called the crowding out phenomenon. And that is, at the moment, the organ system in the United States, however much of a shortage we have, relies almost entirely on altruism of donors, either Caterveric donors whose families allow the organs to be used or living donors. And my concern has been, if you move to a market system, will that result in a falling off of the altruistic donors? We saw a phenomenon like that when we moved to a commercial system in this country paying for blood transfusions. That was a generation ago. Richard's most recent paper does address that question of the crowding out phenomenon. So my resistance is primarily on consequentialist grounds rather than on formal concerns about buying and selling or markets themselves being unethical. But it is an experiment that is not easy to do and once you do it, will you ever be able to put the lid back on a Pandora's box is one of my concerns. So I think I'm going to stop there, Janet, for today. Mark, I was disturbed to learn once and I may have this stat wrong that 50% of the people who have indicated that they want to be an organ donor after death their families who have to, as I understand it, have to concur decline to concur and no organs are harvested. Is there any room or a legislative solution that might say that there is a presumption of organ donation that has to be taken away rather than affirming it in order to proceed? Great question. The answer is absolutely and in fact Illinois passed such a law known as first party consent I believe in the last year or two. Dick, give me a knot of the head. In the last year or two. Illinois was now about the 20th or 25th state to pass a first party consent rule. That meant, that meant that at least in theory no relative could overturn the prior wishes of an individual to serve as a donor if he or she wanted to do so. There are many who believe, as I do, that such a rule already existed but that the transplantation community was always very reluctant to take organs over the objection of the surviving next of kin. And there is a real question whether this new law, the one I'm telling you about, first party consent in Illinois and in the other states will overcome that psychological hesitation to override the wishes of the next of kin and the survivors. It's too soon to know whether the new Illinois law will have any effect essentially. Please. Transplantation theory of age and what I'm wondering is if you're older, should you get and you have two people, the young, the old, et cetera, how do you work that? I'm not looking for it myself. Well, you have just raised one of the most controversial issues that is troubling the organ transplantation community as we speak right now. And that is, that is, there are proposals out there to derive maximum benefit from the available organ. And if you think about this for a moment, if you had a choice between transplanting someone who was 60 or transplanting someone who was 30 and you had one organ in which of those two people would it be most likely that the organ would survive for the longer period of time? And the answer is it would be the younger over the older. And there are proposals currently being debated about whether preferences should be given to younger recipients over older recipients in order to maximize the benefits that would come from any fixed number of available organs. And people have waited on both sides of that because obviously there's an intergenerational conflict that goes on and the question of whether you favor the young over the middle aged or older recipient. So I can't resolve that one except to say that it's very active currently and being discussed. Planning less good organs into the very sick in a way of prolonging their life so that they could maybe get a better organ if you know what I mean. The standards for the organs are very high. And so what do you do ethically there? How do you decide what is the standard of a good organ versus a second grade organ? Gosh, those last four questions could serve as a semester quarter long seminar series. In a situation where you begin with the premise that organs are truly scarce and that they simply are not enough organs. Then the question comes up what do you do in a way every organ falls into a spectrum from let's say a perfect organ to an imperfect organ that is still usable. There was a survey done in the Illinois organ procurement region about 10 years ago that suggested that only 3% and Dick helped me with a livers or kidneys only 3% were so-called optimal organs that is as ideal and as perfect as one would want. And the other 97% was somewhat less good than the 3%. Some have suggested that the better organs be placed into younger people compared to older people. Again that theory that I told you about a minute or two ago. Some have suggested that if your number is called on the waiting list you be given a certain kind of option or choice that is to voice your own preferences. I mean if you're facing imminent death and an imperfect organ becomes available that may be the one you need in order to survive and then if that would have failed you might then qualify to get a replacement organ sooner than you otherwise would. Alternatively if you're not so sick and could wait you might prefer to drop down somewhat lower on the list and allow that organ to go by. At the moment those kinds of decisions are largely being made by transplant teams rather than by individuals although there's variation in that also. But it's a very, very complicated, difficult question and just remember the issue of total scarcity and the general imperfection of most of the organs. A question is how do ethics apply to sibling donations within a family? In contrast to the catavaric donors where you're on a waiting list for a year or two years or three years and you finally receive a donation the living organ donor is really quite different. The living organ donor can make an immediate donation and can make a directed donation. So one SIB could say I would like to make this donation of a kidney to my brother, to my sister to my father, mother, grandparent and what we now know is that the only thing that has kept the American transplant system transplanting at the level that we've been transplanting in the last decade has been the extremely sharp rise in the number of such living donors. The number of catavaric donors for the last ten years is almost flat. It's almost flat at something like nine or ten thousand a year and the number of living donors in that same period has risen from two thousand a year to about seven thousand a year. So the big rise in donors has been in situations I'm not going to say for sure it was a sibling to a sibling but within the family a living donor directed donation. The number of 1.5 million is about the number of people in this country with type 1 diabetes and so that just like there's a big need in China for livers there's a big need in the United States for pancreata and recently it's been in the news that the possibility for xenotransplantation has perhaps had some evidence in its favor. There are many issues associated with xenotransplantation it's one thing you didn't talk about I wonder if we could end with a real sort of science fiction for the future. It's very interesting that you ask about xenotransplant. Xenotransplant is cross species transplant. Do you remember this man, Carell? I mean I can't tell you what a genius this guy was and we didn't give him a faculty appointment. I'm sure Jim Adaris here. Where's Jim? Jim? There Jim. This guy went to the Rockefeller New York and pursued the rest of his career because first of all they wouldn't give him a faculty appointment after his 33 papers in a year and a half and second because they said hey this research is okay but you got to bring in more clinical income. You got it. That's true. But Carell, Carell did three kinds of transplants. I mean let me just tell you he did something he called autotransplants by which he meant he would take a kidney or a heart out of an animal and then sow it back into the same animal. That was an autotransplant. Hearts didn't do so well but the kidneys did alright. They survived because there was no immune barrier. He then did homotransplants. A homotransplant for Carell was you took a kidney out of a cat or a dog and you sowed it into the same species, a littermate often and there sometimes they did not so badly if the littermates were reasonably close genetically. He also did a series called hetero transplants. Hetero meant he took kidneys from cats, sowed them into dogs, kidneys from mice and sowed them into rats. He would cross species and he ran into terrible problems that is the cross species barrier even if you didn't know about immunology was profound. The next person so far as I know who crossed the species barrier was Dr. Hardy in Mississippi who was transplanting hearts from baboons into humans in the 1960s. And incredibly Hardy had one survivor who went almost a year. The longest Xenotransplant in human history was a case in the 1960s when immunosuppression was there but fairly primitive. So the immune barriers have really been profound. It's interesting to hear you talk about the possibility of pancreases crossing species and of course remember my last sentence was I have no doubt that the amount of great basic and translational science that's going to be done in the next century will exceed the one that in the century before and I meant that and so I will work with you and look forward to the Xenotransplants. I want to thank everybody again. Thank you.


Bonjour and hello everyone, can I see a show of hands? Who here thinks chocolateein when they see this picture? Anyone? All right. And who thinks that's very clearly a pan of chocolat? All right. All right. So thank you for our very first survey here. And now that we have so very clearly separated the heathen from the civilized ones, we can move on to less controversial topics. When we started all of this, we had one question in mind. What are the biggest frustrations for web developers and designers today? And I wish answering that was as easy as the survey that we just did. Spoiler alert, it's not. But before we jump into that, a quick intro first. So this is CSS Grid. CSS Grid is a web platform feature that allows developers and designers to lay out a page in two dimensions instead of just one. This was the case with floats and flexbox. And this project that I'm going to talk about, it started shortly, in 2017, shortly after CSS Grid was released. And CSS Grid was a massive success. So in Mozilla's developer relation team, we asked ourselves, how can we support that more? How can we get more of these wins? And how can we, yeah, how can we repeat that? So CSS Grid was a success because it dressed a real user need. And it shipped in all the browsers at roughly the same time and came with tooling, like in the case of Firefox with the grid inspector. And that was seriously awesome. That said, CSS Grid was literally years in the making. And layout had been an issue for developers at least since the times we abused tables to implement our layouts in the 90s. So looking at this, we had a few questions. Why did it take until 2012 to even start addressing that problem? It was very obviously a problem even before that. And why did it take until 2017 to ship something? And how was this coordinated for shipping at roughly the same time? Because most other things are not. And what were the roadblocks? And what were the things that were pivotal to moving this forward? So we took a step back to see what the whole process looked like from Mozilla's perspective. And after interviewing numerous people involved in the process, we identified three distinct phases. There is research, there is standardization and implementation, and there is adoption. Now as you can probably tell immediately, this is a very simplified version that really smooths out many things. And this looks like a pipeline when in reality it's more like a loop or a loop of loops that loop back on themselves. I mean, you get the idea. But this was good enough for us to get started. Most of us had a pretty good idea about the adoption side of things. Because that's really where MDN shines. And we had some idea about the standardization and implementation phase. But we wanted to know more about the research part of this. So how do we learn about developer pain points, what they need, and what we should prioritize for the web platform? So we interviewed more than 10 people involved in different stages of that process. And it became clear that there was no formal research, really. At Mozilla, we have an amazing team that does user research for Firefox. But that's for end users. There's not so much the case for when it comes to developers. We just don't have those resources. And it's important because at a place like Mozilla, as I said, we do have limited resources, so we can't go after everything. We can't just throw everything at the wall and just see what sticks. There are some serious opportunity costs that we have to pay when we decide to do something, because it usually means that we cannot do something else at the same time. And this is what we heard from people about how things are prioritized. So when we talked to people involved in this process at Mozilla, like we haven't tried formal research, like it's all ad hoc. But one thing stood out because every single one of them said the same thing here. We need to hear more from developers. That really stood out to us. And it makes so much sense because none of us can be really successful without that part, without having that. It's hard to prioritize the right things without knowing about developer pain points, and it's hard to find the right solution. And it's hard to get people to adopt something that doesn't solve their problem or doesn't solve the problem in the right way. So for all of these reasons, we proposed a developer needs assessment. What is that exactly? It's a prioritized list of web designer and developer needs. It's a single and simple tool for harsh prioritization across a massive feature space and extremely diverse populations. It's published on MDN. It's not owned by a single browser vendor. So we initially proposed this under the umbrella of the MDN product advisory board, where we have representation from browser vendors, but also from the W3C and industry stakeholders. Because as a community, we have to have at least a common understanding of the facts when it comes to developer pain points and developer needs, even if you draw different conclusions from them. And finally, it's reproduced annually. And this is important. As an industry, we need to know whether we are addressing developer pain points and to understand whether we are prioritizing correctly, we need to track things like their needs and pain points over time so we can see the impact of our own efforts. That's why we need to do this regularly and not just once. And if you do this well, we think the MDN web development needs assessment, or MDN web DNA for short, we think that it can be a voice of designers and developers working on the web. But as I said, asking developers and designers about their needs and frustrations is not trivial. So I think it's important to know that there are some spaces really vast and the audience is extremely diverse. So let me tell you a little bit about the process we went through for that, and I'll make that short, but I already apologize upfront because I'm not a researcher. We worked with a very talented Alison McKeith from Pinpoint Research to design for the research design and to also conduct this. So I'll do my best to channel her here. I'm not a researcher. So in January this year, we started this process by fielding a survey to our product advisory board. And we asked them for data that they would use for decision-making as part of their planning process. And we then had almost 20 in-depth interviews, almost one-hour long interviews each with web developers from around the globe. And we did that before putting the initial version of the survey together. And that's important. That's because we wanted the survey to be rooted in the voices of developers and designers from the get-go. Because if you had run with what browser vendors wanted, the questions would have been based on the internal perspective of browser vendors. By conducting the interviews, we made sure to derive the survey questions from the stories of developers and designers about what was important to them in their work. But also what caused them frustrations. And so to go from interview findings to the surveys, we followed Pinpoint's analysis process, going from observations. That's what we heard and saw. To insights, what it means really to critical themes. That's why it matters. And we are continuing that process to incorporate the survey findings into what we learned from the pilot interviews. So in practice, that means we transcribed 16 hours of interviews. We then coded them and we finally bucketed them to derive insights for the items in our survey. That's a very hands-on approach. But based on these themes, we constructed the central survey question around the frustrations of developers and designers. We then continued to work with our product advisory board on the overall survey with pilot interviews where we watched multiple people take the survey at every iteration to really ensure that survey questions would be as unambiguous as possible. And with the help of more than 30 stakeholders from various MDM PAB member companies, we have put together the final version of the survey and it was fielded in July and August of this year. We fielded an MDM, but not just an MDM. Also through the channels of our product advisory board members, that's a W3C, that's Google, Microsoft, Samsung, and Bookful. We didn't do that just in English. We localized the survey into eight languages. That's Arabic, simplified Chinese, English, French, Japanese, Korean, Brazilian, Portuguese, Russian, and Spanish. I'm very happy to announce that after fielding the survey for four weeks, more than 76,000 people took us up on it and more than 20,000 developers completed the full 20-minute survey. And that was in 173 countries total. So just for the complete responses alone, that's more than 10,000 hours of time contributed by the community to help us understand what their pain points and needs are. And we believe that makes the MDM and WebDNA the biggest web developer and designer-focused survey that's ever conducted. And with that scale, come benefits. So we can segment that data by experience level, developer role, country satisfaction, and we still can get useful information out of that. So after this intro, you might be interested in the actual results. As I mentioned, we had participants from 173 countries across the globe, but of course that's not uniformly distributed. So you can see that just six countries here make up more than half of the participants, and that's the US, China, Russia, India, Germany, and France. And it's a little bit surprising because we didn't even translate the survey into German. That said, we still have a pretty good representation from Europe, Asia, and North America. But especially with Africa, we can really do better hopefully next time where we just got 2% of our responses this year. So one segmentation we were interested in was developer types. There is, of course, the classic split between front-end and back-end. But recently, people have started talking about front of the front-end and back of the front-end. There is no generally understood term for this. We really tried to find one. So in the end, we asked whether people used primarily JavaScript on the front-end or CSS and HTML. That's what most people understood. And as expected, given our audience, only a small number of people saw themselves as back-end developers. And we had curiously an even split between, mostly an even split between JavaScript and CSS plus HTML. But we had way more people considering themselves full stack developers. In terms of experience, our industry is, of course, growing at an incredible pace, so it shouldn't be too surprising that one-third of all participants had less than three years of experience and almost two-thirds of all participants had five years of experience or less. And speaking about representation from previous surveys, we were aware that we would have to make an extra effort and a special effort to get better gender representation. And we did do that, but unfortunately, we didn't fully succeed with that. So women participated at a rate of between 8% and 12% in our survey. And unfortunately, there are no global general population numbers when it comes to software development. But we know from U.S. numbers that women are represented at about 20% in software development, and that's clearly not what we've achieved here. So that is a clear bias in our survey. And it's one we want to better account for in future iterations of this. But for now, we want to at least acknowledge the bias. And we also ask you that you take that into account when interpreting the results. All right, that was a demographic breakdown. But what about actual results? So without further ado, here they are. All 28 needs from biggest frustration to least frustrating. And I want to draw your attention to the top five and the bottom five. So I'll talk a little bit more about the top five and top 10 in a moment. But when we look at the bottom five, there are some surprises at first glance. In particular, number 24, making sites accessible. People who have worked on this know that there are many frustrations involved with that. So why is it ranked so low? And from our interviews, we think it's because accessibility is usually deprioritized. And developers who don't get to spend time on it never notice the issues that are inherent in that work. And that example should make clear that context is super important when interpreting results. So this is a quantitative study. You can answer what and how many, but you can't answer why. And that's why we did the in-depth interviews to get the context, which is also part of our full report. Let's focus on the top 10 a bit more. One thing you might have noticed is that four of the top five items are in a similar bucket. It's web compatibility and interoperability. One of the biggest strengths of the web is that there is no single entity controlling the platform. But that does not come for free. Web developers and designers are frustrated by not being able to use features to find workarounds for things. By having to fiddle with browser differences and by the difficulty to verify that something that works in one browser will not break in another browser. There is another bucket here, though. It's less clear cut, but it shouldn't be too surprising, especially at this conference. The web is not just HTML, CSS, and JavaScript. It's the ecosystem of libraries and frameworks and tools as well. And there is no standard library for the web. There is no default way to build web applications on the web. And that, again, comes with upsides and some very specific drawbacks that manifest here in these frustrations. Documentation and sample code is almost always the top priority for web developers. And generally, all developers, really. But handling multiple frameworks and keeping up with the ever-changing landscape is something that developers find frustrating at a very high rate. I mentioned before that one benefit of large numbers, or large number of participants, really, is that you can slice the data and get more useful results. There is one such segmentation, the top five frustrations between some of the top countries in the survey. And you'll notice that there is very little variation between those countries, despite those being very different markets. But they all share the same top frustrations. And as you know, the pace of change on the web is incredible. So we asked people what their biggest barrier for entry was when it came to new technologies, or when tech becomes available. New tech becomes available. And the results very much, they match the frustrations we talked about earlier. Interoperability and documentation are the leading issues when it comes to why people might not jump on some new tech. This is something to keep in mind. And so far, we've talked about what is available and causing issues, but we were equally interested in what it is that people felt was missing from the web. So we asked, what are the things that you would like to be able to do on the web, but lack web platform features to do? And we had a massive long tail of a wish list, as you can see here, represented by the other category, with 2% of mentions each. And on the other hand, the biggest category by far is about access to underlying devices, USB, Bluetooth, camera, SMS, and all kinds of sensors. We broke out access to the file system as its own category that you can see here, as the biggest request within that larger access to hardware category. And in a similar vein, developers want access to native APIs for contact lists, calendars, and other features of the underlying operating system. And of course, you will notice once again, browser compatibility is very high on the wish list, because what good is a feature that is standardized and shipped in a browser if you can't use it because it doesn't reach that threshold of availability? So I know that this was a bit bleak, so before we finish, I have some good news. We wanted to have one measure that would help us understand what the current sentiment is among web developers and designers. So we asked, how would you rate your overall satisfaction with the web as a platform and set off tools to enable you to build what you need or want? And a full 76% are either satisfied or very satisfied, and only 9% are dissatisfied or very dissatisfied. So while there is room to grow, the web is really an amazing platform indeed. And by understanding what developers and designers spend their time on and identifying their biggest frustrations, we can focus our attention on those and help make things even better than they are today. Which is, well, I'm very happy to share some of the responses we got from browser vendors in response to the survey. So Google came out with a very strong endorsement, and I want to thank the team for that. They said the Google web platform team is now using developer satisfaction, that's the measure from just before. That they're using that as one of our top level success metrics. We're excited to be using the MDF web DNA as one of the main sources of data to help us understand and prioritize the key areas of developer frustration. We shared an earlier version of this report at TPAC in September, and it was very well received by the W3C, which makes me very hopeful. And not surprisingly, Mozilla is on board as well. And what they said was, in the Firefox team, we are always listening to our community's needs in order to make product decisions. And the comprehensive overview of the developer community's needs provided by the MDM DNA report is therefore absolutely essential to us. And we are already incorporating its findings in our plans. So what I just presented, and much more, will be in the full report that we intend to publish this year still. You know, it's already the 12th, but very soon. And we will make it freely available to everyone. I want to thank all of our product advisory board members for their support here, and we invite everyone to use the results to shape their roadmaps to better reflect the needs and pain points of developers and what developers express as their frustrations. But as I said, we want this to be an annual thing, so the next iteration will start in March 2020. We will field the survey in May, and we will publish the results in September 2020, hopefully in time for TPAC 2020 and the 2021 planning season. And with that, well, merci, au revoir.