Let us start our today's lecture for this NPTEL video course on geotechnical earthquake engineering. We are going through the module number 7, which is seismic hazard analysis. A quick recap what we have learnt in our previous lecture. Let us see. We have seen the shortcomings of deterministic seismic hazard analysis and that leads to the requirement of another method, which is nothing but probabilistic seismic hazard analysis, because in this case we take care of all the uncertainties involved in the earthquake event to estimate the hazard for a particular location or region or site. So, we have major characteristics of deterministic seismic hazard analysis like here only a single magnitude that is the m max we consider, single distance r mean we consider and we assume the effect of this m max and r mean to estimate the d s h j. Whereas, in probabilistic seismic hazard analysis we consider all the magnitudes involved, all the distances involved and all the effects involved that is the probability or uncertainty involved in the event is completely taken care of. First in 1969, Cornell through Bulletin of Seismological Society of America B.S.S.A paper first introduced this concept of probabilistic seismic hazard analysis or P.S.H.A. Since then there is a rapid growth in this area of P.S.H.A. and still it is continuing today. So, in P.S.H.A. we have learnt already the input data like seismicity model then seismicity distribution in the space and time magnitude frequency distribution m max maximum possible earthquake ground motion prediction equation or GMPs, which are nothing but attenuation relationships in terms of m and hypo center and site response model. And finally, we will get the output that is the event of exceeding a ground motion level within a time period of t with a probability of p that is what we get as an output. So, the four major steps of P.S.H.A. which we have already seen these are first to identify the sources all the sources and from the site then the recurrence number of earthquakes greater than a subterranean event with respect to the earthquake magnitude then the ground motion prediction equation GMPs based on the uncertainty involved in all the relationship. And finally, to obtain the probability of exceedance of a particular event for a given ground motion parameter. Then we have seen the uncertainty involved in the source to site distance that is we can have various source to site distances if the fault or the rupture is of a large area of course or large length like this. So, what is the mode of considering this uncertainty we can find out r minimum r maximum and all other r that is the distance from site to the source and find out the probability distribution function through the process of histogram for that r. Then we have seen how to proceed with that suppose if we have a linear source like this then from the site we can divide that linear source into a number of segments by either using the concentric circle approach or by using the equal increment approach in the or equality approach in the segment of the linear source. And then find out individual distances which will give us finally, that probability distribution of distance versus that probability of occurrence. Similarly, for area source also we subdivide the area into number of small segments and for volume also we divide it into number of small segments. If we have unequal source that also we have seen we can divide them in unequal areas and all the distances we can correlate to them while calculating the histogram using the weight factor of each of them. Suppose this area is a 1 compared to total area of a. So, a 1 by a will be weighting factor to this distance then similarly suppose this is a 10. So, a 10 by a will be corresponding weighting factor to this distance like that we can find out the histogram putting the weighting factor also. Next we have seen how to characterize the maximum magnitude it is similar to that d s h a process either using all those empirical relationships like with respect to length area or surface displacement of fault or the theoretical determination through the seismic moment concept or the slip rate correlations process. And we often found the distribution is such that earthquake occurrence of low magnitude will be quite often and large magnitude will be very rare. So, based on that Gutenberg and Richter proposed some earthquake recurrence model which will look like this that is if we take any earthquake event at a particular region this is number of occurrence of an earthquake of magnitude scale or in x axis this is the normal scale it will follow some distribution like this which in the log scale of this number of event and normal scale of this magnitude will look like this linear relationship which has been proposed by Gutenberg and Richter through this concept of mean annual accidents which is nothing but number of that event divided by over the time t. So, the recurrence interval is nothing but inverse of mean annual accidents. So, if we plot log of lambda m in this axis the inverse will be log of t r increasing order in the reverse direction of that lambda m, but still they will follow this relationship.  So, these a and b coefficients need to be obtained for various regions based on the collected historical earthquake data. So, Gutenberg Richter law can further be expressed in terms of natural logarithm like this in terms of alpha or beta where alpha and beta is nothing but conversion from the log to the base 10 to natural log through this process right. And the earthquake is expressed in terms of a lower threshold magnitude m naught above below which we engineers are not interested. So, that is why there is a lower boundary hence the lambda m has been expressed by this expression as proposed by McGeary and Arrabaz in 1990. Now, the probability distribution function can be expressed like this if we look for an example of worldwide data of circum-pacific belt the equation is proposed like this we will get for various magnitude of m we can obtain what are their recurrence interval like t r we can easily calculate. But this is also we are not pretty sure whether it is giving the correct result or not beyond a certain value like as it is shown over here. So, we have to select upper bound also up to which this equation is valid or applicable. So, to know the validity of the or applicability of that equation we have to bound it up to a maximum value of m, m max for that region whatever maximum value was accounted for from the known earthquake data. So, that is known as bounded Gutenberg Richter recurrence law hence the equation will change to not only with a threshold value of m naught, but also with respect to this m max. So, hence the modified McGeary and Arrabaz equation of mean annual exceedance rate is given by this hence the probability distribution function is given by this expression considering both maximum and minimum. That means your magnitude should lie between this two ranges of threshold value of minimum and maximum value of this one. Then we have seen for distribution of earthquake magnitude we require all these characteristics of earthquake recurrence law to arrive at all these informations are necessary. Hence the seismicity data and geologic data everything can be clubbed together to obtain a characteristics earthquake recurrence law for a particular region. Also for the predictive relationship we should know the conditional probability considering the standard error involved in the attenuation relationship like this for a given value of m equals to m star and r equals to r star. Now, for the temporal uncertainty in terms of time event how to take care of that temporal uncertainty through the Poisson's model of probability distribution which is expressed in this form. So, if we say occurrence of an event at least once is nothing but n greater than equals to 1 will be 1 minus e to the power minus of lambda n t using this Poisson's relationship. So, we have seen in the previous lecture through example process of that at least once occurrence of that event using this Poisson's probability distribution equation that what is the occurrence suppose an event occurs once in 1000 years on an average then lambda will be 1 by 1000. So, occurrence of that event at least once in 100 years will be like this it can be computed which comes out to be 9.52 percent, but the same problem that is occurrence of at least once in 1000 year probability is not 100 percent what the layman will generally say, but it will be 63.2 percent. Now, expressing this lambda in terms of this probability p we will get what is the annual rate of accidents or the corresponding return period for a 10 percent probability of accidents in 50 years time. So, that gives us 475 years of return period the same thing with 2 percent probability of occurrence of earthquake in 50 years time will give us the return period of 2475. And these things we have mentioned we use for our practical design of any structure in earthquake prone areas depending on its importance that is whether we considered then earthquake event to be occurring in the return period of 2475 that is with less probability of occurrence for an event or with a little higher probability of occurrence with a lesser return period. So, with that we have summarized in the previous lecture that all the 4 types of uncertainties involved are with respect to location that is site to source distance then with respect to size the magnitude probability distribution function with respect to effect considering the standard error in the attenuation relationship with respect to timing based on the Poisson's model. Now, in today's lecture we should look how to combine these all the uncertainties involved for an earthquake event together because these are not independent event all these uncertainties occur together. So, we need to look at the conditional probability or the dependency of one event over the other one uncertainty over the other. So, let us look at this combining uncertainties probability computations. Now, we are starting the combining all these uncertainties using the probability theorem. So, what is the total probability theorem gives us the idea this is the from any basic probability theorem we all know that probability of occurrence of an event a will be nothing but suppose if this is the domain the total probability theorem says us that it will be probability of occurrence of a intersection one event b 1 this is b 1 another event probability of occurrence of a intersection b 2 this is b 2 like that up to probability of occurrence of a intersection of b n right. So, which is nothing but it will be probability of occurrence of a is nothing but probability of occurrence of a for a given b 1 multiplied with probability of occurrence of that event b 1 right. And probability of occurrence of a for a given b 2 multiplied with probability of occurrence of that b 2 and so on up to n numbers of events. So, applying this total probability theorem what we can write that probability of occurrence of any y that parameter hazard parameter which we are going to compute greater than some value say mu star will be given by probability of occurrence of that y greater than mu star for a given x multiplied with probability of occurrence of that event x for entire ranges of x right. That means it has to integrate all these probability distribution functions of x. So, x is nothing but is a vector of parameters which is nothing but all the uncertainties involved that is for a given uncertainty this is the value. So, for all the uncertainties you can get the value. So, we assume that m and r are the most important parameters. So, let us say among all the uncertainties let us say m and r are most important parameters. So, we need to find out the dependency of them in this form that is probability of occurrence of one particular parameter or event greater than some y star will be given as double integration of probability of occurrence of that for a given value of m and r multiplied with probability distribution function of that m and probability distribution function of that r which are coming from the uncertainties involved in magnitude uncertainties involved in the distance right. So, like that we can compute the probability of conditional probability or combining probability together clear. So, again we are writing the same thing in the above equation it gives the probability that y star is the given value which it will be exceeded if an earthquake occurs that is we are suppose interested to know about a hazard that at a site peak ground acceleration occurrence will be more than 0.3 g let us say we are interested. So, probability we need to find out that occurrence of that earthquake p g a greater than 0.3 g for all those given conditions of probability that is magnitude uncertainty is taken care of distance uncertainty is taken care of source to site distance then we can find out the combined probability. So, it can convert the probability to annual rate of accidents by multiplying the probability by annual rate of occurrence of earthquake that means lambda of y star can be computed in this fashion as well mu times of this one this probability where this mu is nothing but that e to the power alpha minus beta m norm. Now, if the site of interest is subjected to shaking from more than one site that is n s numbers of site that is there is a influence of one site from another site then what it should be you should consider while obtaining that lambda y mean value of accidents of y star you should consider all the effects coming from all the sites that is sum of i ranges from 1 to n s of summation of all this integration of the probability. So, for realistic cases probability distribution function for m and r are too complicated to integrate analytically. So, what we do we do it numerically that is we do not integrate it analytically like this, but we do integrate them numerically we will discuss that very soon through examples also. So, now dividing the range of possible magnitudes and distances into n m and n r increments that is instead of doing as I said instead of doing this analytical integration now we are doing the numerical integration. So, for numerical integration we are dividing that m ranges whatever range it is expanding that range we are taking or subdividing into n m like this is number of sites similarly number of magnitudes also we are dividing and number of source distance also we are dividing to n r. So, that is what it says it should take the shape of like this when we are doing the numerical integration. So, this is numerical integration sum of i equals to 1 to n s sum of j equals to 1 to n m that is we have taken care of the integration of the moment function or moment uncertainty sum of k equals to 1 to n r we have taken care of the uncertainty due to the distance v of i integrate of this entire thing delta m delta r which gives us for a given value of probability of m equals to m j because this is ranging over j this r equals to r k because this is ranging over k. This probability individual we have to find out that will give us the final value of this lambda y which we are interested to. Now, what does it mean let us look at it very carefully. So, we have already mentioned lambda y star that mean annual rate of accidents of a particular value say 0.3 g of p g a is expressed in this equation by this equation it is expressed that combining all the uncertainties that is we have taken care of what are the uncertainties number of sites number of earthquake magnitudes and number of distances. So, what all of them are mentioning over here let us go one by one this one i ranging from 1 to n s refers to all sites are considered. What the next term this j equals to 1 to n m refers to this blue color box let us see all possible magnitudes are considered that is contribution of each is weighted by its probability of occurrence that is none of the magnitude we are neglecting we are taking all magnitudes within that threshold value of magnitude and the maximum value of magnitude. What we have discussed through that a maguri equation that the probability distribution function m should be within m naught and m max. So, all the magnitudes with their weighing factor why the weighing factor comes into picture because depending on the number of occurrences of course it will come into picture that is taken care of in this term. What is the next term k equals to 1 to n r takes care let us look at this red box all possible distances are considered in this probability that is contribution of each is weighted by its probability of occurrence that distance probability also we have seen like dividing the distances in terms of r min r max and all other distances from site to source whether it is linear volumetric or aerial or unequal length right. So, combining them we get all the information. So, this term takes care of all possible effects are considered that is each weighted by its conditional probability of occurrence this takes care of your for a given value of m j for a given value of r k that is what it says probability of occurrence of that event of y greater than y star for a given m j for a given r k right that is the combining uncertainties right. Now, how to understand it more easily or in a better fashion let us say when we are doing the numerical integration what we have done we have divided it basically into a number of segments of n m segments and n r segments right. So, we have to look into that two dimensional boxes or systems where n m cross n r possible all combinations has to be taken care of. So, each produces some probability of accidents say y star and we need to must compare this probability of occurrence of that even y greater than y star for a given value of m equals to m j and r equals to r k for all values of m j and r k. So, suppose this axis is talks about all the probability distribution function in terms of magnitude and this axis gives us all the probability distribution functions of in terms of distances. So, we have different histograms for different magnitudes like m 1, m 2, m 3 like that. Obviously, the lower magnitude will have more number of occurrences less one will have higher magnitude will have less number of occurrences like this the histograms will come into picture. Similarly, for the distances also we can get the histograms like this taking the weighing factor. Now, each of them which one contributes say m 2 2 say r 3 this value will be the combined probability like that each of this box we have to taken care of when we are considering this combining of the uncertainties to calculate the probability of occurrence of that event greater than y star clear. So, the compute this conditional probability for each element on that grid just now as we have mentioned this grid and enter that in a matrix that is in terms of spreadsheet or in terms of cell that is what value of that probability you are getting in terms of each of this cell will give you some values then we have to combine them to get the total probability. So, now we are considering the effect of that attenuation relationship say for m equals to m 2 this is your attenuation relationship you will have for different magnitude different attenuation relationship. Now, it is not a single one like in deterministic seismic hazard analysis we have taken this m equals to m max, but here we are considering all magnitudes remember m 1 m 2 m 3 for each of the source right. So, here you are getting this mean value let us say y equals to y star about which we are interested to know. So, more than that at various distances that is these are distance probability r 1 r 2 r 3 each of them will have some kind of standard error. Now, from that probability distribution function above that value of y greater than y star for a given value of m equals to m 2 with a condition of r equals to r 1 is this green color shaded value where I am showing now. Whereas, for probability of y greater than y star for a given m equals to same m 2, but r changes to r 2 will be this shaded portion right. Whereas, for probability of occurrence of an event greater than that y star for a given value of m equals to m 2 and r equals to r 3 will be this shaded portion similarly, for 4, 5 and so on. So, like that all this will give us the probability of occurrence of an event for a given m equals to m 2 for all values of r's. That means, if we look at the grid for m 2 all values of r these are the boxes you are taking care of got it in the numerical integration. Similarly, you can do it in the other way for a particular r for various m you can do that for a given r.  That is why as we have just now mentioned each of them will give you the hazard by computing this conditional probability for each of the element that is for r equals to r 1 with m 2 r equals to r 2 with m 2 r equals to r 3 with m 3 these are the boxes where you are getting that conditional probability clear. Now, you have to repeat this process for each source and value they are place their values in the same cell. So, when it is complete then sum of all of them will give you that lambda value. Now, we need to choose a new value of y star for repeating the entire process is not it because to find out your conditional probability you need to go for another set of pairs of y star to develop another curve. See each of this log of lambda y versus y star will give you final seismic hazard curve like earlier in deterministic seismic hazard analysis we got it in terms of a single value right. Here in probabilistic seismic hazard analysis why what you are getting you should get that log of lambda y star and on the other side it can be log of t r in the reverse direction and that particular value of y star. So, this one single point you are getting by doing all this analysis by combining all these things you are getting only one value corresponding to y star let us say it is 0.3 g we have to repeat it for another value say 0.4 g also like that if you can generate this the combined thing will give you the seismic hazard curve in that fashion. So, it is an iterative process of doing the probability of occurrence. So, that is why most of the time you cannot do it in hand actually you have to use some computer programming to repeat this process of probability distribution and do this process and compute the seismic hazard curve. Now, how we use this seismic hazard curve let us see. So, seismic hazard curve it shows the mean annual rate of accidents of a particular ground motion parameter right. So, a seismic hazard curve is the ultimate result of this probabilistic seismic hazard analysis as I have said this is the ultimate output what you get from a probabilistic seismic hazard analysis. Now, if I want to use that let us see how we can use it. So, say let us want to know probability of exceeding a max value of 0.3 g in a 50 year period from a given probabilistic seismic hazard curve. Suppose, we have derived this seismic hazard curve for a region. Now, how to use it for our design what is the use of that result that result is used in this fashion. We want to know the probability of exceeding a value of a max of 0.3 g. So, in that probabilistic seismic hazard curve which is known to us we should go to a value of corresponding to 0.3 g. Now, drop that in this curve get the value of lambda which you are getting from this curve clear. Use that value of lambda in this now that time related uncertainty event. Use that lambda from your probabilistic seismic hazard analysis curve you put it here. Now, you are interested to know in 50 year span of time what is the probability of occurrence exceeding that 0.3 g. So, put that t equals to 50 over here probability comes out to be say 4.9 percent very low probability. Whereas, if the same result if you want to know for a 500 year of period you will get 39.3 percent for the same result because this value remains same only the t changes in this equation. So, if you solve you will get 39. So, it will obviously have a higher probability when your time scale is changing or increasing to 500 year. So, that depends on what is your design life of your structure. So, that is the way we use the probabilistic seismic hazard curve for our seismic design. Are you clear now where we use this probabilistic seismic hazard curve? Now, let us see the application in another direction that is what peak acceleration has a 10 percent probability of being exceeded in a 50 year period will occur. This is the other way of looking at or using the probabilistic seismic hazard curve. What it says for your structure suppose you want to consider 10 percent of probability of occurrence of an event in the year of 50 year scale. You have decided to go for that. You want to know what is the value of peak acceleration or what is the value of design acceleration you should use. So, this is more realistic use of probabilistic seismic hazard in practice of design. Now, 10 percent in 50 years how you will get for a particular region you have already this seismic hazard curve developed. So, go to that curve corresponding to your 10 percent probability in 50 year what it corresponds to T R it is 475 or lambda value of 0.0021 that already we have seen in our example right using that Poisson's distribution. Isn't it? It is known to us already. So, in that curve you look for lambda value of 0.0021 or T R value of point T R value of 475 years. So, draw that line where it intersects the curve drop it from there whatever value of a max you are getting that is your design value. Suppose here you are getting the value of a max equals to 0.21 g. So, that means corresponding to 10 percent probability in 50 year scale will be the peak acceleration should be considered 0.21 g. So, when with this much percentage of probability in 50 year scale you want to design your structure you have to take peak acceleration for design as 0.21 g. Is it clear how we make use of this probabilistic seismic hazard curve in our practical design procedure? Now, we were talking about contributions from various sources like when we talk about contributions for various sources we have to use various seismic curves. So, we can break that lambda value down into the contributions for each source that is this is the combined or total curve which we have obtained condition considering combined probability that up to NS sources now if you want to know individual source how they affect your seismic hazard curve. Suppose geologist or seismologist gave you an information say source 1 is more active in recent past 100 years period of time. Whereas, let us say source 3 and 2 are not so active in last 100 years time. So, you should always look into not only the total probabilistic seismic hazard analysis curve, but also the individual source representation. That means instead of considering all the sources if you break them or if you consider the each one of them each one of them will something come like this say source 1 is coming like this source 2 coming like this source 3 coming like this. So, in this probabilistic seismic hazard analysis you have taken care of only magnitude and distance probability not the source probability got it. So, can break that lambda values down into the contributions from each sources and plot that seismic hazard curve for each source and the total seismic hazard curve equal to some of these source curves and curves need not be parallel quite obvious. May cross each other it shows that which source is most important that is suppose it crosses crosses some other. Obviously, that will show a significant or importance of that particular source compared to the other source clear. So, let us look at here in an example can develop the seismic hazard curve for different ground motion parameters like this lambda value we can generate for a given y star we have mentioned that y can be p g a it can be spectral acceleration it can be spectral velocity like anything. So, that is what it is mentioned you can generate it for peak acceleration spectral acceleration or any other parameter. Now, choose a desired value of lambda to be used and read the corresponding parameter values from the seismic hazard curves. So, one of them will be the total curve and others will be individual values from that you can get a max value if you are talking about your value as peak acceleration you can get s a value which is spectral acceleration if you are talking about or you are deriving probably seismic hazard analysis curve in terms of spectral acceleration. Now, peak acceleration one example is shown over here say 2 percent in 50 years time for different sources like if it is inter plate event say this is the curve if it is intra plate event say this is the curve if it is a crustal event this is the curve like that we have mentioned for different sources you can identify different curves and you can always say which for a particular region which curve is more predominant depending on criss-crossing nature of them which one gives the higher value of your design value of that a max or s a like that right. Like for example, how do we know for peninsular India it is not the inter plate it is intra plate right from this probabilistic seismic hazard curve only we know that clear. This is the way you can find it out easily for a particular region which source or which type of source dominates whether it is fault movement or crustal movement if it is a plate movement what type of plate movement and all those clear. Similarly, in terms of s a also that is when you are talking about spectral acceleration you can find it out for a given natural period it can be estimated for say t equals to 3 seconds it can be estimated for another time period also why this time period is important because that relates to your superstructure or whatever structure you are going to develop or construct based on their natural period your design value of s a will get guided clear and corresponding probabilistic seismic hazard analysis curve we have to take care of. Next is uniform hazard spectrum or in short we call them as UHS UHS it will look like typically like this that is it is plot of the spectral acceleration versus natural period t like this so find the spectral acceleration values for different periods at the constant value of lambda and for all s a values have the same lambda value that is same probability of accidents with the same probability of accidents you have to find it out this uniform hazard spectrum. What does it mean that means suppose if we want to consider 2 percent of probability in 50 years time with a return period of 2475 years we will get one uniform hazard spectrum if we want to take 10 percent of probability of accidents in 50 years of time that is return period of 475 years we will get another uniform hazard spectrum curve clear. So, different uniform hazard spectrum curve or UHS we will get corresponding to different probability of accidents and accordingly based on your importance of the structure you can select which s a by t curve or UHS curve you should use for design clear. Now, let us come to another subtopic which is known as this aggregation or it is also called de aggregation. Now, common question comes arises like what magnitude and distance does that m x value corresponds to that is when you got your answer here like we have mentioned from a probabilistic seismic hazard analysis curve you are getting for your design value of some value of m x which you can use for your design. Now, you are interested to know that this value arises from which source and which magnitude mostly why because obviously it is having effect from all sources and all magnitudes, but there is a weighing factor. So, which one dominates that we are interested to know. So, what we need to do? We need to de aggregate or disintegrate this result further to go back and look for which magnitude is more influential which distance is more influential for this maximum value of for our design. Why it is necessary? Suppose, if we can avoid or retrofit in some way or disintegrate or can make a kind of isolation from that source that will be very good that is the need for using this concept of de aggregation or desegregation. So, let us look at here desegregation the total hazard it includes contributions from all combinations of m and r already we have mentioned that, but we can break that hazard down into contributions to see where from that majority coming from. So, suppose that chosen value or design value comes out to be 0.09. So, if we disintegrate in terms of distance in terms of magnitude we will automatically say that grid comes from corresponding to 75 and 7 magnitude as shown over here. The different values are there as you can see and among this we have taken only the maximum one already we have chosen the maximum one. So, now we are disintegrating that we are looking at different distances and different magnitudes what are their contributions? We found that major contribution comes from this distance and this magnitude. So, this will be dominating when we disintegrate our data. So, in that fashion if you want to use the USGS site USGS site immediately or little after that any earthquake they disintegrate and give in their site for all various earthquake for various regions the desintegration data. So, that it identifies which source actually dominated it may happen during a major earthquake not only one source was involved may be multiple number of sources were involved. Now, which was the major source to identify that major source this is the desintegration process can be very useful. So, here one example is shown over here you can see this is for Seattle in Washington in US with 2 percent of probability in 50 years time that is with respect to return period of 2475 years with spectral acceleration corresponding to time period of 0.2 seconds that is lower time period you can see that is integration of various magnitudes right. Similarly, for another region like Olympia in Washington only you can see different histograms can you see over here. So, various histogram values are already given in this there is again for same t r value same s a corresponding to t a value of 0.2 seconds same location, but for another natural period look at here once again higher value of time period. Why we are interested about different time period? Because it depends on in that locality what type of buildings are there generally in a thumb rule we will see that later number of story of a building divided by 10 is considered as in a thumb rule I am telling again as the natural period of a building. Suppose if we are talking about 20 story building 20 divided by 10 will be 2 seconds. So, 2 seconds is the natural time period for a 20 story building typically I am saying again it is typically not exact exact time period how to obtain it we will see later on in another sub topic. So, typically t equals to 1 second will denote a 10 story building right whereas, t equals to 0.2 seconds will denote just a 2 story building. That means, this disintegration will give information about which earthquake or which source and which distance is more effective for effecting the shallow buildings or shallow structures or low rise structures whereas, this disintegration data will give us the information that which source and which site are important to consider for a tall story building or high rise structure. Can you see the use of them clear now another disintegration parameter by which we can estimate it mathematically considering this effect of this attenuation suppose we have these values how to obtain this value of epsilon that is the standard error. Error is nothing but area under the curve as I have already mentioned how to estimate that it is nothing but ln of y star that value minus of ln of y bar that average divided by whatever is the standard error involved in that regression analysis that will give you the standard error. So, for low value of y star mostly this standard error or disintegration values will be negative as you can see over here if you select y star value pretty low obviously these values will be negative and if it is above this then it will come positive quite obvious for high values mostly these are positive and large clear. Now, let us come to another sub topic which is important which is known as logic tree methods what it is logic tree methods. Now, we have talked about various uncertainties majorly four uncertainties involved while computing this probabilistic seismic hazard analysis. Now, all these uncertainties are not equally important am I right there can be different there can be different importance of different uncertainty involved in the process. So, we have to find out that most appropriate model which may not be clear about the attenuation relationship and magnitude distribution because the effect which we are considering through attenuation relationship we do not know which model is most appropriate because various attenuation relationships may be available for a particular region like for example, for India for north east India also for Himalayan region of India we have already learnt there are several attenuation relationships proposed by various researchers. Now, which one is most correct and which one is least correct we do not know. So, we have to give different importance based on the experience and expertise that will give us this concept of logic tree to consider different uncertainties. Similarly, for the magnitude distribution also how the magnitude is distributed is also depends on what model you are considering which equation you are using whether it is a empirical relation of wells and copper smith or whether it is a seismic moment based calculation or whether it is a plate tectonic movement based relationship all are empirical relations. So, there also you have uncertainties involved. Now, which model you should give more priority which one list priority you do not know that consideration comes through this logic tree method. Similarly, expert may disagree on the model parameters also like fault segmentation also the maximum magnitude there will be always different school of opinions or different thoughts like different expert will tell this attenuation relationship is good another expert will say no this attenuation relationship is good another expert will say no my attenuation relationship is good. So, how to propose a better or realistic or mathematically more correct relationship or seismic hazard value that is why this logic tree comes into picture. So, let us look at this suppose when we are computing we have various attenuation model some example is given BGF model A and S model let us give equal weightage to them. Let us say we do not want to go any controversy that this is more correct this is less correct let us give equal weightage. Now, within them you can use different magnitude distribution one can use Gutenberg Richter magnitude distribution one can use some other characteristics earthquake magnitude distribution. Now, based on your experience you can give different weightage let us say Gutenberg Richter magnitude distribution relation or recurrence relation is more correct let us say 70 percent weightage is given to that and 30 percent weightage is given to characteristic it depends on the engineers of course. Similarly, for another model now when you are computing M max value you can see for different values you will get different weighing factor 0.2, 0.6, 0.2 here also different values here also different values. How these values are arrived at you can see the example over here. Suppose we are going through this channel this model we have selected let us say we are selected Gutenberg Richter model then for M max 7.5 it is coming 0.5 times 0.7 times 0.2. So, weighing factor or weight factor you should consider as 0.07 when you are using this logic tree influence in your probabilistic seismic hazard calculation. So, final value of that y or the design parameter which is obtained as weighted average will give all the values in the terminal branches. So, these w is nothing but weight factor that is if you go through this model this equation this value weighing factor is 0.07. If you go through this model this equation this magnitude your weighing factor is 0.21 like that different values you are already obtaining going through different attenuation model different magnitude distribution different magnitude values. So, by using this logic tree weighing factors finally, you can get the value of your final y in the probabilistic seismic hazard estimation. With this we have come to the end of today's lecture we will continue further in our next lecture.


All right, hi, everyone. Welcome to the noon case conference. Today it is my pleasure to introduce Dr. Peter Angelos. Peter Angelos, MD PhD is the Linda Kohler Anderson professor of surgery, the chief of endocrine surgery and the director of the McLean Center for clinical medical ethics here at the University of Chicago. He earned his MD and a PhD in philosophy at Boston University, completed his general surgery residency at Northwestern University, and his endocrine surgery fellowship under the direction of Norm Thompson at the University of Michigan. As one of the pioneers in the discipline of surgical ethics, he writes, speaks and teaches widely on ethical issues and surgical practice and how to best teach medical ethics to surgical residents. As an accomplished surgeon and past president of the American Association of endocrine surgeons, Dr. Angelos has published more than 250 peer reviewed papers and dozens of book chapters on his research into improving outcomes of thyroid and parathyroid surgery, minimally invasive endocrine surgery, and best practices for thyroid cancer treatment. He has trained 12 endocrine surgery fellows, hundreds of surgical residents, and has been an inspiration to the over 80 surgeons who have completed the McLean Center fellowship in clinical medical ethics. A very skilled and patient surgeon, thoughtful mentor, and all around exceptional human being and friend. It is my pleasure to introduce Dr. Peter Angelos whose talk today is entitled the value of clinical ethics and contemporary medical care. Thank you, Dr. Apple wait for introducing me very nicely. I appreciate it. Thank you all for being here. I was. I'm happy to get a chance to give this talk today. I know that this has been a large series of talks and so in some ways, this could have gone at the beginning could have gone at the end. But it's in the middle. And so that's because there was a speaker in May who couldn't come in May but I thought it would be good for you all to hear him so he's given the last one and that's why mine is in the middle. I, with that said, I will go right ahead, assuming that I can. And now suddenly I cannot. Interesting. Okay. So, I have no disclosures. And so by way of outline, I'm going to talk about really three things what's distinctive about clinical ethics. So a little bit of time talking about the mission of the McLean Center this is a work in progress, but I think it's valuable for you all to see how we're thinking about it. And then I'll talk a little bit about moral distress and clinical ethics and how I think those things are related in just a couple minutes about future directions. So, by way of contrast, I want to think a little bit about the difference between bioethics in a sort of general sense and clinical ethics, and, and to quote the Britannica online, a reputable source, according to some bioethics is a branch of applied research that studies the philosophical social and legal issues arising in medicine and the life sciences, chiefly concerned with human life and well being, though it is sometimes though it sometimes also treats ethical questions related to the non human biological environment. So, obviously a big topic, and an important topic. And so, so, and here I'm quoting from Edmond G how who has been the editor in chief of the Journal of clinical ethics since 1990. This is 1990 volume one issue number one. Dr. How wrote the focus is not on armchair ethics, ie the theoretical exploration of ethical views, but on the application of ethical inquiry to solve problems at the bedside to help clinicians and patients. And it's really this focus on at the bedside, helping clinicians and patients. I think that was sort of the driving force of the founding of the McLean Center, and, and the founding of the McLean Center is completely to the efforts of Dr. Mark Siegler and Dr. Siegler I appreciate you being here today it's really an honor that you're here. So, Dr. Siegler was on the editorial board of the Journal of clinical ethics from day one. He had a series of articles in the very first issues of this journal that help define clinical ethics. And, and so, so it is important to think about this distinction of clinical ethics being a very applied discipline as opposed to a more theoretical bio ethics. Now, I would say that the purview of clinical ethics has widened over recent decades. And certainly, I think we know that the focus is not purely on the patient caregiver interactions. That's been the case I think for a while now, and clinical ethics today does need to attend to how the decisions we make on multiple levels of health care impact the outcomes of patients. So I do think that we can talk about big system issues, and it's still clinical ethics, if our focus on the big system issues is really, well what's the impact on patients of those decisions. The role of clinical ethics ought to be the improvement of the care of patients regardless of where among the many levels of a system the changes are being made, at least that's what I've suggested. So, I do think that there's something that's distinctive about the focus of clinical ethics. The argument that I want to make now very briefly and I won't go into a lot of detail, but I think it's not just that the scope has changed. But that there's a little bit of a different series of things that we think are important when we do clinical medical ethics as opposed to sort of theoretical bio ethics, and I'll try to explain that a little bit. So, so the attention to how we answer what should be done is different in these different realms, although they overlap. And so let me use a case to help illustrate that difference because I'm hopeful that the case will make this more clear than I've been able to so far. This is a case from the University of New Mexico trauma service I was there as a Disney professor a couple months ago. And the trauma team told me about a patient I won't go into all the surgical details because they're not relevant but the the important things 22 year old man was involved in a high speed motor vehicle collision. He suffered multiple fractures and had severe traumatic brain injury. The patient so social factors that are important. The patient is not married. The parents were the surrogate decision makers there was no controversy about that. He had no advanced directives. So the things that we might ask about in clinical case conference. I think those are important things so a few more details. He was found to have really no significant neurologic function over the next few days testing confirmed death by neurologic criteria. Again, you know, you, you have heard many discussions about what that criteria is and whether there's controversies about that. For the sake of discussion of this case there was no controversy. This patient met the criteria for brain death. Important parents don't speak English through an interpreter. They're found to have very poor health literacy. So the parents response to the news that the, that the patient that their son had died was, and you know this is not a it's in quotation marks but it's via translator so it's not exactly a direct quote but it was essentially, he looks just like he did. When he left the house that morning before he got in the accident, don't stop the ventilator, or you will be killing him, and we won't allow you to do that. And the, the, the, there was a discussion about organ donation and you know that all of the things that generally happen when a patient is declared dead by brain death criteria. They had no interest in that because he wasn't dead. And the father said, it's, I'm going to become violent if you turn, if you think you're going to turn off the ventilator, it's not going to happen. And I'll make sure it doesn't happen. And so really did threaten violence and, and people were concerned that he was really very serious about it. So, the question and, and you know when you're visiting professor one of the fun things is that people get to ask you, you know, the tough cases, and, and you know if, if I'm a visiting professor for endocrine surgery they asked me about well what would you do for this thyroid cancer. If I'm invited more for ethics than it's a case like this. So, you know, what should be done. And, and, and I do think that, you know, I said well what do you all see as the problem. And so they said well there's a brain dead patient taking up an ICU bed in a busy urban medical center. We feel as though this is inappropriate use of resources were squandering resources. And, and this idea that the parents are refusing to accept brain death as death, certainly problematic. And as is my general practice when I'm asked tough questions is to ask a lot more other questions to the people there. And so ultimately, they told me what they did. But let's pause before we get to that. Let's think a little bit about what would theoretical bioethics answer what should be done here. And this is perhaps, you know, an unfair strongman argument but I'm going to make it nevertheless. I would say that bioethics would say hospitals treat patients.  And there's no dilemma. You turn off the ventilator and you make the bed available for a patient who needs it. And it's sort of like, what's the problem, because from a theoretical point of view, we don't really have any responsibility to bodies other than to treat them with respect, but certainly not to keep them in ICUs taking up bed space from someone else. Now, in contrast, the clinical ethics perspective which interestingly enough was what the trauma team did. And this was, you know, if this case had happened long before I was ever there so I had nothing to do with it. But there, what they did seem to me very much fits with the way we think about clinical ethics. And their thinking was although there's a need for beds immediately turning off the ventilator would be traumatic for everyone. So traumatic for the parents, traumatic for the doctors, the nurses, everybody involved in the care of this patient. And they felt that they had some responsibility to the parents, interestingly enough. They should think a little bit about the parents' well-being and not solely about this issue of what do we do with bodies and hospitals when we need beds. And their sensitivity to the parents and other caregivers, they felt that that warranted a delay in the removal of the ventilator.  Now, why three days rather than two or four? I don't know. I didn't make the decision. I wasn't caring for the patient. But their idea was we have to give this family a little bit of time to grieve, to sort of come to grips with what was happening. And during that time, they had multiple family meetings. They tried to explain what brain death meant that he, despite how he looked, was never going to be waking up, was never going to be going back to the way he was. And they looked at this as an opportunity. The trauma team said to me, well, we can't help the patient, but we can help the parents. And in their assessment, that was a reasonable way to justify the use of resources. Now, it's pretty expensive. No question about that. We could have conversations about that. But other family members were involved in the discussions and ultimately helped the parents to accept the death of their son. And so they turned off the ventilator. There was no violence. The father was not happy. But how could you be happy in this circumstance? So, so what I think is important in this case is not so much about, you know, could they have done things differently? Could they have tweaked things? But was the outcome a success? Now, from a bed utilization perspective, one would argue, you know, right, you kept an ICU bed occupied and unavailable to someone who could benefit from it for a period of time. But there was no violence. That seems good. And although the, as I said, although the father remained upset, other family members helped him accept the inevitability of the discontinuation of the ventilator. And I do think that in this sort of family's narrative of what happened to their son, waiting three days had value. And I would argue that it had value because it allowed them to come to grips with this in some fashion and allowed them to then sort of tell the story of what happened to their son in a very different way than would have been the case otherwise. And I would argue that this case hopefully illustrates to some extent that the scope of concern in clinical ethics appropriately is cognizant of some things that might have been missed if we were taking a much more theoretical approach to the problem. And I do think that as we see on a weekly basis, decision making in clinical ethics necessitates attention to not only the patient, but to those who care for the patient. And those who care for the patient are sometimes the family, the surrogates, and also the professional caregivers in the hospital. And so those who care for the patient, I think it means both of these sets of people. And if you look at this, I would say for those of you who may be familiar, this seems to sound a lot like what has been described as a care ethic. And so for those who may not be as familiar with it, I'll just say a couple words. The ethics of care developed largely in response to principalism and Carol Gilligan 1982 book is sort of largely credited with sort of starting this idea. The ethics of care rejects a hierarchical view of ethics in favor of a more relational one. And it's sort of, I guess, anthropologically grew out of what she would Carol Gilligan described as a feminine view of how decisions are made which are as much less hierarchical. And the argument goes something like persons interact in networks of relationships rather than in isolation and the relationships and human connections matter. And so when you're thinking about what's the right thing to do those relationships then become very important. And rather than taking a deductive approach from ethical principles a care ethic looks to the specific situation again sounds a lot like clinical medical ethics and solutions to conflict are sought in the context of the parties involved. And the goodness of a decision is determined by the manner in which it enhances the relationships. So we say, well that was a good decision. If there's been some sense in which we have strengthened the bonds, the relationships of the parties involved. So obviously one could spend a lot more time delving into an ethics of care but I do think that this idea of what things we think about when we make decisions. You know, why is it that in Dr. Siegler's book clinical ethics that the four boxes, the four box model, why does that include the family and surrogate decision makers. Well, because they are important in the decision making. And so that those relationships then I think are matter and good solutions according to a care ethic resolve conflicts and improve relationships. So, let me turn now to the second of my sort of three major things to talk about today. And that is the evolving mission of the McLean Center. And so, certainly the mission of the center has grown in recent years. And in the last several months. There's been a deliberate effort to revise and update our mission. And I do want to really give special thanks to associate and assistant directors. For all listed here, Marshall Chen, Megan, Applewhite, Micah, Prohaska, Monica peak, Lori Zoloft, and broad knee Julie core Valerie Coke and will Parker, all of whom have been involved in some of these discussions. And so, I do want to just share with you a draft version, we're still working on this this is a work in progress. And certainly we'll have more formal opportunities to discuss it but I thought it would be a good time to have a preliminary conversation. So, the mission then of the center as we're thinking about it going forward is to innovate and excel in clinically driven ethics inquiry education and service that improves care, transforms systems, advances equity and informs policy to improve health for patients and communities. And it's not different, but perhaps a broader view, and the vision statement is for fair just and equitable care of individuals and communities that maximizes their health and well being. Now, there are then a number of ethical commitments then that we would be making if we're going to actually have this mission and the end this set of values. And that is to engaging collaborative trans disciplinary inquiry and education that integrates ethics and clinical biological social and humanistic sciences to improve the care of individuals and communities to explore ethical issues in healthcare through rigorous research methods guided by conceptual models and rooted in clinical relevance to address and engage the ethical issues that impact health outcomes at multiple levels, including patient family clinician organization community and policy to build mutually respectful relationships with individuals including patients families and communities to challenge norms as agile innovative thought leaders to train and mentor the next generation of leaders in healthcare ethics inquiry and service and to be a beacon for humanism and social justice in healthcare. Now, certainly very aspirational, but there's no sense, you know, writing it down if it doesn't give you something to shoot for my opinion. Now, let me turn then to talk a little bit about this third issue. And this is a little bit of a sort of a different idea, which is how burnout and moral distress might be impacted by clinical ethics or our attention to clinical ethics. So we know burnout is an important issue in medicine. And I'm not sure whether there's an epidemic of burnout or just greater awareness, but either way, it's a problem, we should attend to it. And I do think that, you know, we have to realize that burnout is a risk factor for depression and suicide, which are clearly huge issues, not only for the medical profession and everyone involved in hospital care, but for society and, you know, at least among physicians there are about 400 physicians a year commit suicide. So it's this is not trivial. Now, there are a number of factors that have been associated with caregiver burnout. These have been described by others and so again I won't spend a lot of time on a loss of autonomy, a diminished sense of value in clinical activities, some people say the electronic medical record that's the root cause of it all I'm not sure that's true. It doesn't help but it's not the problem in its entirety. Some people have said that inclusive language may actually devalue individual contributions. And so if we talk about providers that suggests a cog in the wheel rather than someone essential like my nurse or my doctor. And so, maybe that has a role I'm not sure. We know that there are certainly personal characteristics that might reduce the risk of burnout. And again, lots of attention has been given to this resilience is something that, you know, we're told we should be more resilient we should be able to bounce back from adversity and that will make us less susceptible to burnout. The capacity, the ability to bear the many unavoidable irritants of daily life with relative equanimity. So having greater capacity in this context would seem to protect us, in some sense, from the risks of burnout. And starting I think around 2018, we started having resilience week for GME for the medical center. I was particularly impressed in the 2019 resilience week happened to fall during the polar vortex. I don't know if you all remember that, but I was really I thought it was very ironic that it was canceled due to extreme call. It seems like that you should be resilient enough. But anyway, that's a totally different thing. But it was all canceled because it was very cold out. So, you know, could there be aspects of providing medical care that increase our resistance to burnout. Well, I think so. And I actually think that by emphasizing the ethical dimension of the care of patients. That may help us as caregivers, as well as helping our patients. And so, just to give you a sense of why I think this is the case. The moral injury and caregiver distress again are things that have been widely described in recent years moral injury is described as occurring when we perpetrate bear witness to or fail to prevent an act that transgresses our deeply held moral beliefs. And whether it's moral injury or moral distress, putting the needs of patients first, I would say is central to the deeply held moral beliefs of most physicians nurses and other caregivers. And every time we're forced to make a decision that contravenes our patients best interests. We often feel a sting of moral injustice and over time these repetitive insults amass to what people have described as moral injury. So, again, you could argue with the definitions, but certainly there is something here to be concerned about. And more burnout and moral injury may be complimentary views of the central problem of clinical distress or clinician distress. Interesting that burnout suggests that it's my problem I suffer from burnout that I lack resilience, whereas moral injury. Describes the challenge of simultaneously knowing what care patients needs but being unable to provide it due to constraints so it sort of pushes the problem away from me and my own personal characteristics now you know there there are some pros and cons of this move. I think it's important to think about how that happens. And some people believe and I think there's some very, there's a lot of truth in it that long term solutions to moral injury demand changes in the business framework of health care. And that there may be limits to what we as individuals can do to mitigate these things in, in the context of the system in which we work. The question that I'm interested is how might attention to the ethical dimension of patient care mitigate this issues of burnout moral distress. And I do think that regardless of the practice setting one is in the individual relationship of a caregiver and a patient is an intensely personal one. And, you know, we do ask our patients to trust us individually, as well as to trust the institution. And I do think that responsibility to uphold our patients trust is a central motivator to medical excellence, regardless of sort of the context in which we practice regardless of our specialty, regardless of exactly how we care for patients. And, I mean, I think, to me, if you reflect on why do many people choose to go into medicine. Well, it's the opportunity to help people right that's the classic, you know, interview question for medical school why do you want to be a doctor, because I like helping people. Right. I guess, maybe you don't get asked that question anymore I was definitely asked that question, and I answered the same way. You know, if there's any joy in medicine or surgery, I would say, and I think there is personally but you know everyone has to make their own decision. It's about helping patients. And so if there's no sense in which I gain some joy out of helping patients then I think that's problematic. And regardless of how devalued any of us may feel in our jobs for each individual patient. And again, for me, I'm asking them to lie down in the OR and let me cut their throats. But, you know, in any, anything that we do in medicine, we're asking people to trust us quite a bit with either personal information, or intimate details about their physical emotional psychological lives. And so all of these things, I think, if we realize the impact that we have on patients, that I think that may help protect us against the risk of burnout. Now, how do we then emphasize this this ethical dimension in healthcare. Well, I think that we need to take seriously how well or how poorly we communicate with patients. I think that it's not. So in, you know, in surgery, we talk a lot about informed consent, right, we talk about risk benefits and alternatives. But we know that communication is much more than here is a list of the risk benefits and alternatives. That's not communication. And I think that we need to emphasize the development of communication skills in our optimal education and practice. And I would say we need to acknowledge the central role of trust in the relationships between caregivers and patients. And I think that we frequently don't do that enough. And it was it was striking to me when I was recently reviewing our University of Chicago's informed consent form, the actual form that patients signed before they go into the operating room. And unless I read it wrong, which is possible, I didn't see trust anywhere in there. It's much more of a contractual relationship, which I think goes very much against what we're in fact trying to present to our patients. Now, there are many things that we can control and things that we can't control and lack of control. Without a doubt is a major source of frustration felt by many physicians nurses, everyone who works in large institutional practices today, and probably in every other industry as well. Although I can't speak to those others because I've never been paid to do anything else. Well, I was paid to scoop ice cream one summer. And I used to do professional magic and I got paid to do that, but that was a long time ago. But so so there is, there's a, when there's a loss of control that I think increases our risks of burnout. And the interesting thing is that, you know, in the privacy of the exam room, when I'm there with a patient. When I have control over that interaction. I'm the one who can decide well, how much of an effort do I put into engendering that trust, how much of an effort do I put into ensuring that my communication is actually effective, rather than just I've turned the switch and I'm doing my thyroidectomy spiel in which I talk about risk benefits alternatives. And I do think that despite the time pressures that we have in the care of patients today. There's no administrator that can affect how well or how poorly I engender my patients trust. That's ultimately up to me, and it depends on how seriously I take that as a responsibility. So we know and I'm going to just talk just for a minute about surgeons because that's what I know about. You can think about in other areas in healthcare how much this applies. But multiple studies have pointed out that serious, the serious detrimental impact of complications on surgeon well being. So we know if we have a complication that's bad for patients. It also has a negative impact on the well being of surgeons. And some people have described the surgeon as the second victim of a complication. Now, if you're the patient who had the complication. I'm pretty sure you would say I don't really care that much about the second victim I'm worried about the first victim and I understand that. But from a caregiver perspective. This is a potential issue to think about, and lots of institutions have sought to reduce this impact and there are some departments of surgery for example that have here counselors and so if you have a complication then you know you can call the peer counseling hotline. I was visiting an institution a couple years ago where they have a program where if anything bad happens. Caregivers, no matter what their specialty what at their field is they can call it's referred to as the swaddle program. And so, and I, and I asked the department of surgery that had invited me I said so you know do you get a lot of surgeons calling the swaddle program, and they said, zero is no surgeon says, I need swaddling. So now, you know, that's a problem. There are, you know, worthwhile interventions these and probably many others maybe even more effective. I would also suggest that focusing on the ethical dimension of surgical care might also help. And I do think that by ensuring that the adequacy of informed consent is a way to engage our patients in the decision making process and certainly shared decision making acknowledges that the surgeon does not always know best that does not always know best, and that complications can and do occur.  It doesn't diminish the physical impact of a complication on a patient, but I do think that it has a significant impact on the psychological implications, both for the patient and for the physician. Because if I say, do you remember when I had that conversation about how I might injure your recurrent laryngeal nerve, such that your voice is permanently a horse. Again, that doesn't make it better, but at least I think it reduces some of the stress associated with that conversation. So, you know, hopefully, I have at least given you a little bit of a thumbnail sketch about why there's value in acting ethically. I do think that patients benefit from ethical surgeons. I do think that caregivers can also benefit from a greater attention to the ethical dimension and again, I say surgical care, but it's everything we do in hospital so it's not limited to surgery. I do think that the attention to the ethical dimension requires caregivers to attend to expertise outside of medical science. If we think that communication is an essential component of being a good caregiver in the medical field, then we should realize that we may not be the experts at communication and other things. So, you know, I do think that increasingly everybody involved in healthcare is faced with a dilemma. And that is that we are increasingly pushed to measure outcomes and quantify results. And you know the movement towards quality in throughout medicine is all about sort of measurement. And that's a good thing. Lord Kelvin said nicely if you can't measure it you can't improve it. Kelvin, right? The guy who, what's the thermometer, I think? Kelvin scale, yeah. I remember that vaguely. Unfortunately, it's really difficult to quantify ethical behavior. We can't measure it in the same way, but we still have to encourage it. And Einstein said it nicely, not everything that counts can be counted and not everything that can be counted counts. So, I'm going to end with just a few thoughts about sort of future directions. And I do think that we have to acknowledge the distinctive features of clinical ethics and embrace this broader role that I think we can have. I think that we have to embrace the value that clinical ethics can bring to patients, families and surrogates as well as to caregivers. I think that we have to endeavor to live up to our mission and that we have to work to make the vision of fair, just and equitable care a reality for all of our patients. And we have to aim to improve the health of patients and of communities. And so a few final thoughts. I've only got 30 more slides, so we're good. It's a joke. I think it's good to be ethical. I hope that that is not a controversial statement. I think that it's good to be ethical because it's just good, right? There's an intrinsic value, but there's also I think a value for patients and caregivers. I do think that the scope of concern for clinical ethics appropriately considers the impact of patient decisions on the families and surrogates. And I do think that the mission of the McLean Center focuses on not only patients and caregivers, but also on the community. So last two thoughts, I think clinical ethics will remain the core of the center's mission, but contemporary clinical ethics must have a broader focus than it did 40 years ago. And I do think that this greater attention to the ethical dimension of care may prove benefit not only to patients but also to caregivers. So with that, I'm going to end and I'm very happy to answer questions. Thank you. I noticed I wanted to slide your condition of the McLean Center. One of the lines is that it's sort of switching from clinical ethics to healthcare ethics. I'm really interested in sort of that, that sort of switch because I couldn't demand healthcare that much for our clinical ethics and doesn't bring into play the ethics of the systems that we want to learn. Sure. So I think that the membrane can sort of play more directly to the resource allocation question, or even sort of business. Yeah. Where are the appropriate products for the healthcare system to expand in terms of sort of making decision more talk about to our community. If I understand this a bit, how does that work? Yeah. And what that means to you when you use the term healthcare efforts? Yeah, thanks. Thanks for asking that question. You know, I think that I believe that it is that clinical ethics actually covers all of that. And so in some ways, I think that there's been, I think, and part of what I've tried to suggest is that clinical ethics should be thought of in a much broader scope than we have in the past. And so it is true that the health system and the policies that impact that health system have a huge implications on what happens with individual patients. And so in that context, I think it is within the scope. And I think it's appropriately something that the center should be interested in and focused on. Now, in some ways, if as I'm suggesting, even things like global warming has implications on what happens in the hospital, right? So, you know, what choices I make in the operating room about what instruments I use and how many instruments I use and whether they're disposable or not disposable things like that. You know, all of those things you could argue, well, those are decisions that affect an individual patient but also have a much broader implications for sure. In some ways, the question becomes if everything is encompassed within clinical ethics, then what's not? And I guess it's, to me, it's not so much what's not, but how is our focus, you know, what makes it clinical ethics? And that's where I do think that this sort of practical implications at the bedside rather than a completely theoretical framework. I think that's where I would rather try to make the distinction rather than sort of how big is our scope of view, if that makes sense. Dan, sure. Yeah, yeah, it's a great point. And I mean, there is no question that if we, if our focus is really just on who's in the room, who's around the table, as it were, that sort of presupposes a sort of a first come first serve. You happen to be in the bed and so now we're more concerned about you than someone else who, you know, never gotten the bed yet and so we don't know them. So, I think that that is true. There is, there's an asymmetry there, and I'm not quite sure how to manage it. But it is, it's a reflection of the reality and to the extent that it should be, that reality should be changed. I'm not sure, you know, I, but I would agree with you, it's, this isn't, this isn't a solution per se, but perhaps a way to get to a solution. Yeah. Yeah, Mike. There's also an over-reliance on that assumption and what meant that the community could actually stop engaging theirself about, you know, about, I suppose, about whether or not this is going to affect patients. I think I probably made this up, but I feel like Marcus told me about being here when they came up with intensive care units and it was like, you know, well, let's, let's figure out what the right thing to do for the patient is. We'll be on this technological new thing that we're doing feels, in some sense, very similar to the story that you described. The other thing that I think will be very interesting that wasn't quite here, but I feel like there's a lot of discussion about professionals in medicine. Yeah. Definitely amongst the trainees, there's sort of an existential fight about what is professionalism and what's right. Somebody gets into the burnout and I think that that will probably have impacts on our clinical ethics because, you know, many of us that trained in a single generation came up with the idea that there's a way to do things ethically and non-ethically. It can be care of patients and now the professionalism part of that challenge and that may result in, you know, changes to our ethical norms about what we think. Right. Yeah, no, I think absolutely excellent points and, and you know, I do think that that's, I mean, all of those things suggest to me that far from sort of feeling like, well, you know, we benefited from Dr. Siegler's sort of his emphasis on the ethical implications of the decisions that we make at the bedside every day, right? We don't need to get an ethics consult to realize that, right, we're making ethical decisions all the time. But I do think that, you know, your points further emphasize the idea that we're never going to get to a point where we've put ourselves out of business, right? We've solved all the ethical issues. There aren't any more, right? We've got it confined because it's, we now I think realize that the scope is both broader and the impact of the decisions at other levels that have an impact on, you know, what happens in, in a individual patient case. So thanks. Mark. Yeah, I think that you know, for the bioelected, starting in the United States, 1966. 1966 was a year that I graduated from here at the university. The bio-efficers were brilliant, brilliant people, with peer reticions and scholars, legal scholars, they were fantastic. Anybody know what percentage were physicians or surgeons or physicians? The original. And so, by 71-72, as I finished the Chief Presidency here at the university, I decided that it was essential that the bio-efficers who were not physicians and were not directly working with physicians wanted to be added to the bio-efficer mission. And so that's when I started in 71-72, the field of clinical medical records.  And it spread around the country, all the way into the next 10 years. And in 82-83, we went officially to the commission for our president, the university, who established it. So we should go around the 42nd and 43rd year, and we would have had a great addition to the program. But this is really, really down here. And I'm just so proud of that. Thank you, Mark. Thank you very much. I appreciate it. All right. Any other questions? No? Okay. Well, thank you all very much. I appreciate it. Next week, we have an outside speaker, Dr. Tolkien from, not J.R.R. Tolkien, but a different Dr. Tolkien, from Yale. And I believe that we are in this room, and I believe that lunch will be provided, but only if you sign up. And so we have tried to get this room, because obviously it's more conducive to discussion than P117. But since we almost had to fight off the pharmacists, because they thought they were scheduled in this room, make sure that you check your calendar, because we may be going back and forth between P117 and here. So, all right. Thank you all very much.


like a particular date, right, in a particular year, and that year is for a variety of reasons. We can talk about 1776. Anybody know what happened in 1776? Three things happened in 1776.  What is the one thing you know? What happened in 1776? The Declaration of Independence of the United States was written. Now, why do we care? You live in Singapore and you care about the Declaration of Independence of the United States. What relevance does that have? It has huge relevance. Because the Declaration of Independence represents a set of ideas that have made us rich. Without the ideas articulated in the Declaration of Independence, we are still, 250 years ago, good poor. What are the ideas that the Declaration of Independence articulates? The idea that as an individual, you have an illegal right. Inalienable means what? Means nobody can take it away from you. It's part of who you are. Not even a majority. Not even a majority. It cannot be taken away from you. And you have a right to what? To your life, to your liberty. You all pursue happiness. The Declaration of Independence is a declaration of the individual's right to his life. It's a declaration that the individual has a right to the free, to be free. To be free of coercion, free of authority, free of people telling what he cannot do. Free to live his life as he see fit in pursuit of the rational values he needs in order to live. And it's that freedom that the Declaration of Independence articulates, which is what made us rich. That same year, a famous book was written. Now it was published. Anybody know where the book was published in 1777? Well, that was Nation's. Well, that was Nation's by Adam Smith. It's not an accident that the theory around economic freedom, the theory around capitalism is coming out at the same time as people articulating their ideas of individual liberty and individual freedom. Because the two go together, capitalism is the system of individual liberty and individual freedom. It's the system in which individuals are left free to live their lives as they see fit. To pursue their values, to pursue their own happiness. The third thing that happens in 1776 is consistent with both of those. The steam engine, which had been discovered many years earlier, but really way back, the steam engine is first commercialized in 1776. So now somebody using his own judgment, using his own mind, not asking for permission in terms of starting a company and innovating and building something, but just doing it, starts a company using the steam engine to produce stuff. And that sets off the industrial revolution and it sets off the complete change in the world in which we live. For the first time, for the first time, when people are asked who is your life belong to, they don't answer. Well, what do people answer in the past? Who does your life belong to? The king. What's that? The king, right? That's one answer. What else? His life belongs to his wife, but you know, some people have those kind of relationships. Who does your life belong to? The god. It's sorry, the god, right?  I'm going to do it right away. Yes, sir. Your life belongs to him. He gets to tell you what to do. Who else does your life belong to? What's that? The general, the army. The general, the leader, the tribe, the community, the group. Somebody. Your life belongs to somebody. And he's just waiting for this. The parliamentarian. Maybe your life belongs to the parliamentarian if you're a good office. Okay? If you're a good Nazi, your life belongs to the army and race. And to the leader who dictates what it's going to be. Psychically, your life as an individual never belonged to you. It belonged to the tribe, the group, the state, the king, god. 1776 declared, no, my life is mine. My life is mine for the first time in human history. And the consequence of that have been astounding. The consequence of that are the skyscrapers in Singapore. The consequence of that is all the wealth that surrounds you here and globally all over the world. It is individual human freedom. It is our willingness to stand out and declare that our life belongs to us as individuals. That it's changed the world in such a dramatic heroic fashion. Your life is yours to live as you see fit. That idea is what generated the wealth and the prosperity that we see all around us.