My name is Barry McClain, and I have the privilege of beginning this, the 20th anniversary conference of the McClain Center. And I thought I'd start by telling you a little bit about my mother, this amazing woman who was introduced in 1984 by Stan Goldblatt to Mark Siegler. When I saw Stan Goldblatt's going out to the washroom, I think, so he won't hear this. But in any case, mother had had an unsuccessful procedure, and I'll give you the technical name. It's an aura femoral bypass at a hospital here in Chicago, and it didn't go very well. And as an interested person about my mother's health and knowing the pain that she was enduring, I sought counsel, so I went to a friend, a trusted friend and great friend in Stan Goldblatt, and he said, well, she ought to meet Mark Siegler. So that was back in 1984, approximately, and my brother David is here, but perhaps Dave, you can give me a better date if I think that's correct. He says 86, I think it's 84, but... In any case, what happened was that Mark and my mother became engaged in what, and obviously following various tests, and what might be done to help her condition. And ultimately, the University of Chicago re-performed that operation much to the success of my mother. And obviously during that process, they shared lots of ideas about outcomes-based information. They developed a doctor-patient relationship of consequence. Mark became a great friend of my mother. My mother became a great friend of Mark's, very genuine. My mother became a great friend of the surgeon, Chris Zerans, who, how many people remember Chris Zerans here at the University? And they teamed up to tell my mother outcomes-based information says, you should stop smoking at the age of 85 years old, and so she did. And that's because the data you presented to her and the information, and she believed you. So it's been really an extraordinary experience for my mother to have known Mark and then Chris and lots of other people in this room and elsewhere. And then to start this conference, which she believed in the whole idea of knowledge, of sharing knowledge with one another, of the advancement of science or the world around us through knowledge. She was a person who believed in knowledge for knowledge sake. She constantly was reading, writing, even in her later years she would write papers. She was a very gifted woman who graduated from high school at 16 or 17 and received a graduate degree from Smith in English at the age of 20. And so she met my father who was a student nearby Yale and he was the same age and he graduated with an undergraduate degree in engineering the same year my mother graduated with a master's degree in English. So she was a learned woman who believed in seeking knowledge all her life. And somehow I think today she's watching us and watching the achievements of what she's helped to create both through the conference and then the family endorsement of the McLean Center. So it's really been a privilege for our family to be involved and to have known Mark and encouraged Mark and try to help Mark on some things we're pretty good at too. And with that said, I'd like to do is to introduce my brother who's here from Virginia and his wife Carol David, can you raise your hand? And then we have his son Jimmy Jim and Corinne McLean if you'll wave your hands. So the first, as best we can interpret it, the first student of the McLean Center was in 1984. So that was 24 years ago. That first graduation took place 23 years ago. And since then no less than 240 individuals have graduated through this program and have gone on to be faculty members and hospital administrators and people who are affecting the lives of a much larger population all over the world. And so it's with that we start this conference officially and Lenny Ross is next. Thank you. I want to thank Barry and Marianne McLean, McLean Board and everyone else who supported us to this date. I also want to thank the two guys who kicked me to get this conference organized, John Lantos and Peter Singer. I wanted to start the conference by taking a look at Mark's influence at 20,000 feet and then we'll move from the big picture to some of the smaller pictures by looking at some of these papers. But let's start at 20,000 feet. Seven month old Joshua Skidmore is in Chicago this evening for a second chance at life following a dramatic mid-air rescue onboard a jetliner. Joshua is seriously ill, he needs a liver transplant. He was being flown to Chicago from his home in Mississippi on Tuesday when he went into respiratory failure and Marianne Childress is here to pick up the story. Floyd Little Joshua is in critical condition at Weiler Children's Hospital. He has neonatal hepatitis, a condition that causes liver failure. He needs a liver transplant to survive and that's why he's here in Chicago. But this story is about his trip here which became a literal fight for life. Doctors are optimistic that seven month old Joshua Skidmore will be a candidate for a liver transplant. Although he's very sick he has a fighting chance thanks to the heroic efforts of a Chicago doctor aboard a Delta jet somewhere in the skies over Kentucky last Tuesday night. The Skidmores were bringing their son here to the University of Chicago. They were on an 1145 p.m. flight out of Atlanta. The plane had just reached cruising altitude when Little Joshua went into respiratory failure. I jumped up out of the seat and went and got the stewardess who was having trouble with the baby breathing. So she immediately run forward and said, is there a doctor on board? Dr. Mark Siegler answered the call. He headed the Center for Clinical Medical Ethics at the University of Chicago and had taken the flight at the last minute after a speaking engagement in Georgia. He was in a situation where flying up in an airplane with a baby not breathing there was no technology available. We opened the medical kit but there was nothing there that could be used for the infant. Although the baby still had a pulse and heartbeat he'd stopped breathing. So for the next 24 minutes Dr. Siegler performed mouth-to-mouth resuscitation while the plane headed for an emergency landing in Louisville, Kentucky. It was the most basic intervention which is the traditional intervention that's been known since classical times and that's the breath of life. By the time the plane touched down little Joshua was breathing on his own. The first time we got a cry out of the baby after a couple of three minutes of this mouth-to-mouth resuscitation the mother and I looked at each other and we knew we were on the right track. It was the best cry I had ever heard from a baby. He said he wasn't really supposed to be on that plane. I said yes you were. I said you may not have known you were supposed to be on there but God had you on there for us. Little Joshua was rushed to Children's Hospital in Louisville where his condition was stabilized. Yesterday he was flown by Air Ambulance here to Chicago. Doctors say that he's now in in-stage liver failure but they're very optimistic about his condition and his chances of undergoing transplant surgery. Sometimes pictures say it all. To stay on the theme of 20,000 feet we also, Ella Dutton who's Mark's RA this year has spent a couple of hours locating all of us around the globe and here are all 240 former fellows visiting faculty and where they're currently located so during the breaks come up and enjoy where we all are a world global view of Mark's influence. Our goal today is though to just move from that global view and to come back to Earth and to do a bit of reminiscing as well as to give you an update about the McLean Center and where we are 20 years later. Our goal is to examine really twofold first how Mark has influenced clinical ethics and number two how Mark has influenced all of us and then finally we will talk about where we're going to go in the next two decades. So on that what I'd like to do then is to introduce the first speakers who will talk about the McLean Center at its inception and our first speaker will actually be Dr. Al Tarluff. From September 1999 until July 2005, Dr. Tarluff served as director of the Multieuniversity Texas Program for Society and Health in Houston, Texas where he was also professor in the University of Texas School of Public Health and the Sid Richardson and Taylor and Robert H. Ray Senior Fellow in Health Policy at the James A. Baker III Institute for Public Policy at Rice University. He has now returned to Chicago where he previously served as professor and chairman of the Department of Medicine at the University of Chicago from 1968 until 1981. He's also been elected to membership in the Association of American Physicians and to the Institute of Medicine and if I were to go on and on about Dr. Tarluff we wouldn't actually get back to Mark. So I'll stop there and please ask Al Tarluff to join us. Thank you, Rainey. In 1968 when Mark Sigler was in his second year of post-MD training as a resident in Chicago here, I became chairman of the Department of Medicine at that time. So I want to cover this morning those years, initial years for Mark here, from 1968 to 1982. The Department of Medicine over its first 40 years became nearly 100% subspecialized in internal medicine. In its organization, its faculty composition, its outpatient operation, its inpatient bed assignments, and in its teaching. The extinction of the generalist internal medicine orientation, particularly for medical students, was thought to have a detrimental effect on their education. We at that time envisioned a striking new generalist subspecialist balance in the department's activities. We created a new section of general internal medicine. A specifically designated general internal medicine outpatient clinic was opened at that time. We reassigned the department's 200 plus beds to carve out 36 beds for general internal medicine on what then was W-5. And we envisioned then recruiting from outside and developing from within a new faculty, having maximal potential to grow as superb practicing academic internists and teachers in the mold of some of the most distinguished clinicians of prior generations, including McGee Harvey at Johns Hopkins, Robert Lerb at Columbia, and which was exemplified institutionally in the reputation and clinical excellence of the British medical care system of medical education. Our first recruit, Dick Binney, who's sitting in the second row here, was a product of the Columbia University System and a student of Grant Little at Vanderbilt University. He arrived here in 1971. He was and is a superb clinician teacher. He assumed the directorship of general internal medicine here and in that way came into contact with Mark Sigler. The year before Dick arrived, Mark had finished his residency training and was selected as the chief resident in medicine for 1970-71. Mark as a resident had demonstrated extraordinary skills as a teacher, a clinician, a leader, and a humanist. I attributed at that time Mark's notable humanistic instincts to his attendance at religious school in his childhood and in his adolescent and to his majoring in English literature at Princeton. This was a much too simplistic explanation, of course, but it was good enough to secure an entry-level faculty position for him. And until recently, I believe that. We wanted Mark for our faculty in general internal medicine. During his chief residency here, we talked about his future and the desirability of him building on his clinical strengths to further develop as a teaching clinician. I would say that in those conversations, I heard a lot of really unusual stories about his plans for his future. And they were, I'd say unusual, I'd say that kindly because they were really off the wall and weird. But at any rate, we obtained funding for him so that he could take his first year at the Great Hammersmith Royal Postgraduate Hospital in London, which was 1971-72. Upon his return to the university in July 1972, shortly after Dick Binney also arrived here, he joined a new section of general internal medicine. While Dick became director of house staff training for the Department of Medicine, Mark became director of medical student education. Mark also became director of a newly created three-bed intensive care unit on W-5, carved out from three rooms up there with the connection being made to all of them. It was one of the first ICUs in the city. Looking back on it now, it was a nightmare because there was no, the modern equipment that we all take for granted wasn't available at that time. But at any rate, for Mark, being the attending physician on the outpatient department but also on the inpatient general medicine service for eight months a year and being attending on the ICU and director of it but attending four months a year and in addition, building a large practice in the outpatient department, Mark was totally and completely immersed in patient care and teaching. The clinical work and teaching was decisively influential on him, on every dimension of his professional interest and affect. He became a consummate clinician which then and today sowed the seeds of his every thought, every thought about the ethics of patient care. In the ICU, he asked penetrating questions about who shall live, who shall die, on what grounds can a decision be made as to which waiting patient gets the next precious bed in the ICU. What are the essential features of a productive doctor-patient relationship and how do you touch them, how do you teach them, how do you impart them to students and others? A lifetime career in clinical ethics was conceived and born from his natural instincts for empathy, respect for others regardless of their station in life, a sense of fairness, a hope for justice and a continuous, joyous pursuit of discovery of new ways of serving human health. All of that stems from his openness to questions from patients, families, nurses, doctors, other faculty, clergy and others. Mark perceived the need to learn more about the theories of the academic field's neighboring ethics such as theology, philosophy and law. He reached out from the medical school to the broader university community and formed collegial relationships. Indeed, these were tutorials. It was an incredible thing. This was a faculty-to-faculty tutorial system that he developed with Professor James Gustafson, Stephen Thulman, Father Richard McCormick and many others. Good fortune came Mark's way in the summer of 1975 when he was accepted into a six-week seminar underwritten by the National Endowment for the Humanities held at Williams College titled Humanities for the Medical Practitioner. The seminar organizer and leader was William May who was here in the audience and will speak later this afternoon. While at the seminar, Mark learned that his first paper was titled Pascal's Wager and the Hanging of Cray. Now I can tell you that being at that time I was relatively young too, but I had read by that time a medical literature for 15 years and I had a high regard for the New England Journal of Medicine and when I saw the title of that paper, I cringed and thought, this is no time for joking, Mark. But they liked it at the journal. It was accepted for publication in the New England Journal of Medicine. The paper is a classic in my opinion. It sought answers to a question that was germinated in the ICU. How should a physician talk with a family about the prospects for living of a loved one who was at death's door? Pascal was followed in the next few years by seminal papers. In 1978, on teaching clinical ethics at the bedside, in 1979 on the limits of clinical medicine, in 1981 on revision of the doctor-patient encounter, in 1982 on confidentiality in discourse with patients. Each of those five papers early in his career are going to be discussed here today and tomorrow. Each has been drawn from Mark's experiences in the ICU and on the wards elsewhere in the hospital and on clinical ethics consultation rounds which were discovered, which were invented here. First developed by Mark and now frequently seen in other teaching hospitals, but they have become a linchpin making ethics deliberations common throughout the entire medical center. Well, to sum up my view of things, Mark's astonishing development, adolescents have converted the word awesome to a cliche. So I gave up using it about a decade ago, but I want to use it today. I have been truly awestruck with the growth and accomplishments of Mark Sigler. To put it in academic currency, can you imagine going from an instructor having a truly bizarre plan for his life or even no plan at all to a failed attempt to gain tenure earlier in his career? To Dorothy Jean McLean's vision of a center to improve the quality and outcomes of doctor-patient relationships. Then on to being named the Lindy Bergman Distinguished Service Professor at the University of Chicago. Forward to being appointed to the Board of Trustees of Princeton University and then last year to receive perhaps the highest honor that can be bestowed on a member of the faculty of the University of Chicago, being selected as a 2007 Nora and Edward Ryerson Lecturer. Awesome, indeed. Thank you. It's now my great pleasure and privilege to introduce Ann Dudley-Goblat, who's been a faculty member at the McLean Center for Clinical Medical Ethics since its inception. She has taught health law to virtually all 240 fellows at the McLean Center, including half a dozen lawyer fellows who now hold academic and non-academic positions around the country. Ann Dudley received her law degree from Harvard and her LLM from the University of Chicago. She is also a member with her husband's stand of the McLean Center Advisory Board. Ann Dudley. I think you're sure you're still alive? It sounded like a eulogy. I'm going to go over some of the same ground but in a slightly different vein. Mark was sent to England after his medical school here in large part by Al because he was thought to need seasoning. I didn't know what that meant, but now maybe it was the weird life plan. He returned, and I met him soon after his return, he returned with a springer spaniel named Swift about to have a pair of twins, a brace of guns, and I am not making this up, a heavy tweed shooting suit that included knickerbockers for going through the gorse to get the grouse. Actually, I believe that his eternal interest in organ transplantation comes from the fact that right after I met him, his dear Swift had end-stage renal disease and his desperate attempts to keep Swift alive, hairless at this point, were unsuccessful, I'm afraid. But he was a little bit misinformed because he thought the new way of the University of Chicago was if you were a really good clinician and a really good teacher, you didn't have to worry about this research and publishing and grant stuff. That was a mistake. So he opens the ICU, the Met ICU, and gets incredibly depressed because they all died and it was not a happy physician-patient relationship, which even then he was very concerned with. At that time, Chase Kimball had just come to the University in the psychiatry department and when Mark said, you know, this is a downer and I need some help in this area, he said, look, we have this guy, Jim Gustafson, just come here from Yale. He has taught virtually every medical ethicist that exists, this is in the early... Now, they were mostly theologians at that point, but they were all very well trained. So Mark goes to Jim and they create a seminar, and they all said, weekly, you did cases, you read, you did this, you met Stephen Tullman, and Jim Gustafson also gave him two waifs, Martin Cook and me. So these are two people I've been mentoring and they're interested in what you're interested in. And so take them, maybe take them off my hands, I don't know what it was. So that was the first time we had clinical ethics program, 74, 75, and we would go onto the floor and Mark would find cases. Now, this was a hard time because if you remember in the middle 70s, everybody was tough doctors, especially the women, and they never saw ethical conflicts. So we had to pull conflicts out of the air, of course they were there and all of that. And at the same time Mark wrote this, about 1975, wrote the Pascal's wager, that was the theological part, and the other part was this radical idea that maybe it would be better to be honest with patients. You could actually prognosticate realistically and create a collegial relationship with them. That was the beginning I think of what Mark has maintained throughout his career, this total attention and regard for the relationship between doctor and patient. And it's really unique fiduciary capacity. About this time, he was going for tenure, do you go for tenure? He was applying for tenure, he was requesting tenure, he was hoping and praying for tenure, and he'd had one paper and one grant. The very first grant that HD, the Department of Health and Human Services, whatever it was called then, had given to him, but it wasn't enough. And this is a remark that he said to me about three months ago, so he has it verbatim. He was called into the Dean's office, this was soon after Dan Tossison was seduced and sent, seduced and went to Harvard and Bob Yuritz was taking over the deanship. And Mark went into Dean Yuritz's office waiting for his tenure acceptance. And Dean Yuritz's first words to him is, Mark, it's been wonderful having you here at the hospital. This was not what he wanted to hear. So both Mark and his friends, which included at this point, my husband and myself and many others, Neil Harris, just a whole bunch of people, were very upset that maybe this wonderful clinician, this wonderful teacher, wasn't going to get tenure. But luckily the next year you got it. I don't know how that happened and really don't want to know. It's like making sausages. Don't want to know that. And he goes to Williams. And still, except for Dr. Pellegrino, we were still dealing in medical ethics. There was no such thing as clinical medical ethics. It was medical ethics. It was almost all policy. And it was primarily theologians and philosophers. And a few like Leon Casso were either both or were not quite sure what. But there were very few clinicians involved. But Mark was already involved in that and he came back and something wonderful happened to him. DJ fell for him. He fell for DJ. Both of those are very easy to do. And he got a muse. The best kind of muse, a muse with money. And she said, you need to expand your scope, not just your patients, but other people's patients. And that was really the beginning. In the very beginning, the ethics center was all faculty. We used to have these lunches in the little conference room at the entrance to the brain research. And they were wonderful. But it was quite clear that we were all preaching to the converted there. We were all together. And thank goodness for DJ. He said, just a few. Just get a few people. Well, a few people he got in the beginning, I hope some of them are here. Abigail, Sugar, Steve, Miles, John Lantos, John Lapuma, Peter Singer. I mean, these have become major elements in the field. And it was a little informal for a while. And then, and this is basically where I get to stop, because is it Laney who's going to do it? Joe. Oh, good. Okay. We started getting much more organized. Carol was here. John Lantos was already here. Steve Miles was here. Steve Miles, by the way, was the first person at the University of Chicago to take maternity leave. I mean, so we knew we had something special going. He has continued on for the past 25 years, now emphasizing two things. One, real cases. That's the Steve Tullman side of him, and maybe a little bit of me, I hope, but very casuistic approach. Stay dedicated to real things. Policy will come out. It's a very deontological approach. No, it isn't. It's the other one. But anyway. Yeah? Okay, yes. Right. Well, it's certainly casuistic. And then the second is this continued absolute dedication to the doctor-patient relationship, to honesty and collegiality. Now, honesty and collegiality, there is, dare I say it, a paternalistic element in Mark's medical approach, but it is a familial paternalism that is open, if not to reproach, at least, or rapprochement, at least to a negotiation. Mark has consistently attempted to follow DJ's request to expand knowledge that's knowledge increase from something to something that life may be enriched, and also his advisory board who keeps wanting to expand the number of students. And this morning we had an advisory board meeting in which we discussed the complete solving of the organ transplantation problem of access and enough organs. Then we discussed the opening of the Global Health Initiative, leading me to believe that next year we will have an intergalactic ethics program. So I think DJ is very happy with what you've done, Mark. Thank you. Our third and final reminiscence will be from Joel Howell. Dr. Howell is a professor at the University of Michigan in the Department of Internal Medicine, Health Management and Policy and History, as well as the Victor C. Vaughn Professor of the History of Medicine. He received his MD at the University of Chicago and stayed here for his internship, residency in internal medicine and a fellowship at the McLean Center for Clinical Medical Ethics, and maybe we'll get actually a year so we'll know how many years we really have been doing this. He then went to the University of Pennsylvania where he was a Robert Wood Johnson clinical scholar and PhD in the History and Sociology of Science. Dr. Howell has been a faculty member at the University of Michigan since 1984. Please. I don't know, Mark. I'm learning more about you all the time. It's a really great honor to be here to help celebrate this occasion for Mark. Obviously, we're going to spend most of the next day and a half talking about the content of his work. I'd like to talk just for a second about the context to try to historicize the development of the McLean Center. And I do so because there's a real risk when we look at the world as it exists today of assuming not only that something should exist, but that it was inevitable that it would come into existence. And I don't think that was the case at all. Sometimes the purpose of history is to look at the contingent nature of change to describe how and why and when certain institutions came into existence, as well as to reconstruct the world of the past, doing so whenever possible, not through the malleable selective omissions and distortions of our own individual memories, but as far as possible using the bread and butter of the history, which is the primary sources, and I've tried to do that whenever I could. So let's go back to the world of the 1980s. Though it might not be obvious today, I want to emphasize just how profound a disjunction the formation of the McLean Center was. And the previous speakers have certainly alluded to this and given some background for it. Yes, the Hastings Center had been founded about a decade earlier in 69. Yes, the Kennedy Institute in 71. But I would argue that neither was deeply embedded in the clinical world. Yes, there were ideas about clinical ethics that were out there. There was a conference in, for the Siba Foundation Conference on Kidney Transplantation in 66. The Wallace Conference on Pediatrics Research in 72. Looking at neonatal medicine, of course the Belmont Report in 77. But these committees were not permanently established. They were not ongoing. They were not reproductive. The overall environment when you look back was hardly propitious for the kind of tasks that Mark undertook. In the early 1980s, wanting permanently and meaningfully to establish clinical ethics within a distinguished department in medical school, Mark, I think you were swimming against a tide, the strength of which is hard to imagine today and impossible fully to explain in my limited time. Only a few decades earlier, funding for basic science had exploded. The NIH, which previously had supported virtually no extramural research, was pouring money into medical centers both well-established like the University of Chicago and others that were relatively new. And Mark, I still remember. I don't know if you remember when Don Selden came and gave grand rounds here. And I sat there not far just across the midway, and you and I together listened to him talk. And what he said, and you allude to this in your paper on the nature and limits of clinical medicine, which is in the selection of readings, what Don Selden, a very distinguished leader said, a giant, a lion, he said to me, he said to everybody in the audience, he said, this sociocultural stuff, forget it. Your job as a physician is to do science. You deal with science. You deal with disease. You deal with facts. You deal with knowledge. And I say this not to wring out one person, but because he was very, I think, very much in the majority. And that was the tide against which Mark was swimming. And that's important to realize that now it seems so obvious that we need the McLean Center. It seems so obvious that we need to consider these issues. It was not obvious then. And I think your story about tenure points out that it wasn't obvious to everybody even here. Now, clinical ethics was out there. It was in the air. And how did Mark make it happen? And I'm going to cut some stuff here because I think that Dr. Talhaven has expressed and others have expressed so eloquently the importance of the clinical side of what Mark did. I just say, I saw this firsthand. You may not remember, but when I was an intern in my very first rotation, you were my attending. And I and everybody else saw this incredible passion and enthusiasm for patient care that others had described better than I could. It also meant that you had not just academic credentials but deep personal legitimacy. And that, I think, enabled Mark to talk to a wider audience. We do not have included in our readings the op-ed pieces that Mark wrote for The New York Times in the early 1980s. But I want to reflect back on those because I think they're very telling of the kind of person that he was and the fact that he was speaking to a wider audience, academics, but to the country at large. There was one wonderful column in which Mark said, how can we make physicians more humane? And he said, and I think you were right, you can't teach people to be humane in medical school. You either are or you're not. So we need to select more humane physicians. And how should we do this? You had a couple of ideas. One was maybe we should have applicants write a book review and then defend it over a beer in a local pub. I suspect you had Jimmy's in mind, I'm not sure. And the other suggestion, I think, that was prescient in the 1980s. In 1982, I believe it was, might not seem that prescient today. But again, in 1982, when there were very few women, at least compared to what there are today in medical school, Mark said one solution is that we should have more women in medical school classes. And I think you were right about that as well. Another op-ed explored several reasons, moral and otherwise, why doctors should provide free healthcare. So I think this is an example of how he was thinking broadly and engaging a wide-ranging audience. I want to make one more brief historical point. There's an enormous literature in the history of science that looks at which laboratories, which research groups, really have an impact. And which ones don't. And the ones that have an impact are the ones that are able to reproduce themselves. And so the decision to have a training program at the core of the McLean Center, I think is absolutely critical to its success. And this map illustrates the extraordinarily wide sweep and wide scope of the sorts of ideas that you were putting out there in the early 1980s. And I think that this is a very telling and very important lesson. And finally, although my time run at short, and this isn't really strictly speaking what I was supposed to talk about, I must express my enormous personal respect and gratitude. Not just for me, but for a whole cohort of physicians who have worked in the humanities and social sciences. With all the trials and tribulations, Mark, you were the first person to get tenure in a major academic medical center with your research firmly based in the social sciences and humanities. The first one. And so I think that you have served as an exemplar for a whole generation, many of whom are in the audience here, of physicians who have followed in your footsteps. The intellectual rigor of your work and your enormous passion for the subject have helped us all. And I think that all of us are not just patients and not just those people who are at the McLean Center, but all of us who have tried to work in that area owe you a tremendous depth of gratitude. And I thank you. We're going to skip forward 20 years. And it's my privilege to introduce our current chairman of the Department of Medicine, Skip Garcia. Dr. Garcia is the Lowell T. Kageshaw Professor and chairman of the department since 2005. He came to us from Johns Hopkins and did his medical degree training at the University of Texas Southwestern Medical School, completing his residency in internal medicine at the University of Iowa Hospitals and a pulmonary fellowship at Albany Medical College. Please help me welcome Dr. Garcia. Well, thanks a lot, Lanie. Lanie asked me to maybe just say a few words about where the center and our relationship with Mark, where we stand today. And then she will follow this up with some much more detailed comments to Lanie and where the center is and the bigger scope of things. But I do appreciate the opportunity to talk to you all today about Mark and about the center, because obviously this is a tremendous source of pride for our university, but particularly our department. I don't think it's any secret to this audience that the secret of its success has been its focus actually on the real world of medicine and on the real problems that are confronting nurses and physicians who take care of patients, both in the outpatient setting in the hospital and as we heard today about the critically ill. Now, I knew that there was a lot of bonds between Mark and myself, but clearly one bond is that I'm an ICU trained physician and I was just really excited to understand about how Dr. Tarlove asked Mark to start the first medical ICU in the city of Chicago a while back. And it really resonates with me because of the problems in which Mark encountered in that job, as you've heard from Al and from Ann as well. These are the problems that, you know, in my own career I've had to grapple with as well. The care of delivery to the critically ill, the end of life decisions, the informed consent, the surrogate decision making, and of course as Al very aptly and ineligently delineated this allocation of very scarce resources for the critically ill. So I know that this helped shape Mark's career in that way and it again just shows how the breadth of Mark's ability to reach and touch and resonate with so many aspects of our trainees and our faculty is really simply a spectacular issue. Now, at the core, of course, of where the center is today, you know, it's a spectacular success. It is absolutely without doubt a premier medical ethics program in the country where its flagship, of course, is the fellowship training program. We'll hear more about from Laney, but, you know, the number of trainees that have been through the center, the number of academically intense over 170 physician trainees in the center that are still academically involved and internationally acclaimed is just an amazing feat. In our hospital, we have in the department lots of awareness of the consultative surface that was started by Mark in the center. This is obviously a very unique service that attends and addresses issues for adults and children both and is coupled very tightly to a multidisciplinary conference which is, you know, really simply spectacular and the envy of many medical ethics programs around the world. I think that this conference provides a form for engaging our trainees and our faculty in issues of humanism and the physician-patient relationship in ways that other institutions can only dream about. But I think one of the essential pieces and I'll just close with this thought, one of the essential pieces of the center and Mark's amazing vision for the center has been its linkage to mentorship. Obviously, we know that the classical three legs of the academic stool are clinical care, research, and education, but that fourth leg is truly mentorship and Mark has understood that from the very beginning, obviously mentoring a number of you in the audience in ways that are very special to you and to Mark, but as well as to me. He has a new chair here at the University of Chicago. Mark was of enormous help and very, very mentorily in his advice and in his ability to be there to help me navigate these difficult problems. But Mark has recognized the need for a structure to the mentorship in the center and has provided a very strong infrastructure in which mentees and fellows are matched to a really amazing diversity of individuals with rich skill sets that include theologians and philosophers as well as clinicians and lawyers and economists. And I think this really is at the very heart of the success of the program and of its trainees. So in closing, let me just say as chair of a department that houses the McLean Center, I am just enormously proud of the accomplishments of the center and the center continues to bring great pride to our department. But I think one of the early aspects of the success of the center is Mark's vision for reaching out beyond the department to other clinical departments, first pediatrics and then surgery. And now it's fully integrated across the university bringing this new knowledge and this new expertise to this program. And that really underlies the true brilliance of Mark's leadership of the center. So with that, I'll just close and say thank you Mark and it's a great honor to be here and be able to talk about it. So it's my privilege to give the update of the McLean Center. So here we are today, a fresh gift and honor of Mark. The McLean Center today, the center faculty has over two dozen physician faculty members. We're supplemented by faculty from philosophy, history, sociology in the law school and in fact in this past year we have six new faculty members. The fellowship we've trained over 240 fellows and over 80% remain in academics. Two new initiatives in the past few years first is the beginning of a surgical ethics program in 2006, the first of its kind and in fact in the last two years we've trained over a dozen surgeons which is more than we had done in the first 18 years. We also have now a new two years master's degree program that began in 2005 and have trained three fellows to date. Today there are many ethics programs around the country and around the world. Many run by McLean Center graduates as I'll be showing. The McLean Center however remains the first and foremost program focused on clinical ethics and the doctor-patient relationship. And the McLean Center faculty do remain committed to the tri-partite mission of academic medical centers, clinical care, research and education. So looking at the three pillars in clinical care we have over 100 clinical ethics consults annually. Our main focus in the recent years has been on end of life care and decision making capacity. We have a weekly ethics consultation service that many of you have attended which attracts over 50 participants weekly. In research last year the faculty and fellows published over 200 articles in the peer-reviewed literature and we attracted grants from the NIH, non-profit as well as local foundations. And on the education component, many of you remember fondly the summer intensive which continues to exist for five to six weeks with three lectures a day, five days a week. Sort of like the booklets we sent out to you a little bit too much always. The coursework is scheduled now. For those of you who were here at an earlier time it's now all compressed into one day in order to allow fellows to pursue other training and careers. The current one-year fellowship this year includes 17 one-year fellows, the largest class ever, which includes six surgeons. We also have this year four senior fellows and one two-year fellow. But let's focus on Mark and his influence and I want to start with his influence on the clinical ethics community. So one way of thinking about it is six degrees of separation with Mark in the center and look at his influence. So here, just to give an example, our current 2008, 2009 faculty and what you can see is how many were former fellows as well as how many are new faculty appointed since 2005. We also though have former fellows who have academic achievements around the country. We have one dean and president. We have a number of former fellows who have endowed professorships. Here is a list of all the faculty out there. Many of you are here today and I thank you who have full professorships. Here are former fellows of the McLean Center who are or were directors and chairs of ethics-related programs around the world. It's clear that it's all two degrees of separation if you know Mark. But let's focus now on Mark and his influence in the peer-reviewed literature. And so this, some of you can go back to the 1970s but when you go on the computer you only get articles back to 1989 showing the number of publications that Mark had every year. But more interesting is the number of times these articles have been cited on a yearly basis with a peak of over 300 citations in the year 2003. But when you think about Mark you don't think about Mark publishing you often think about Mark co-publishing with many of his peers.  And the answer is Carol Stocking with 41. John Lantos with 26. Peter Singer with 22. We get into the single digits. We get down to the threes and the twos. And then if you go for one citation or one degree of separation the slides keep coming. But let's focus on Mark and his influence on the libraries of the world and I don't mean to suggest the clutter but I do mean to look at some of the books. First is Clinical Ethics. Now in its sixth edition including the recent Kindle edition and then for Mark's colleagues and former fellows we have books by current McLean faculty here and then from books from all of his former fellows and visiting faculty and again it goes several pages. So it's an incredible accomplishment. It's one that is a great place to be. We hope you always feel like you can come home. Thank you very much. So it's on those notes that I want to end the reminiscing at least for today we'll get to do some more on Saturday morning. What I would like to do though is to now begin the substance and here we'll begin with clinical ethics the field will look at how it began and Dr. Pellegrino promises me he's taking it back much before 1990 but we're going to look at then and clinical ethics the field in the current. So let me begin by introducing Dr. Ed Pellegrino who since 2005 has been the chair of the president's bioethics council. Dr. Pellegrino's professor emeritus of medicine and medical ethics at the Center for Clinical Medical Ethics at Georgetown University Medical Center where he was the John Carroll professor of medicine and medical ethics and the former director of the Kennedy Institute of Ethics the Center for the Advanced Study of Ethics the Center for Clinical Bioethics and an adjunct professor of philosophy all at Georgetown University. He has also served as president of Catholic University, president and chairman of the Yale New Haven Medical Center for Health Affairs at the University of Tennessee founding chairman of the Department of Medicine at the University of Kentucky dean of the School of Medicine at the State University of New York in Stony Brook and founder of the Health Sciences Center there. Please help me welcome Dr. Pellegrino. Thank you very much lady it's a real privilege to be here for me it's almost as Yogi Berra would have said deja vu all over again because just a few years ago I had the privilege of delivering the McClain anniversary lecture in honor of our honoree today in the years since then my admiration over all of these years has been growing by leaps and bounds there's every sign and you've seen those signs numerically portrayed Mark's trajectory of success will continue his place in the history of bioethics is secure as a result of Mark's work and Mark's students and the McClain Center University of Chicago has really become the preeminent focus nationally and internationally for training research and practice in clinical ethics and the centerpiece of Mark's work and the one I think which he will most often mentioned and praised in the years ahead is his interest in the physician patient relationship the clinical encounter situation in which a person seeking assistance comes to a physician trusting and hoping and that's a moment that will happen to each and every one of us and it's a moment which Mark has done so much to illuminate it's at the central, the moral center of clinical ethics indeed of medical ethics entirely and I think what I would like to do this afternoon is take a little liberty with the question of the then and talk a little bit about the perceptions of the physician-patient relationship what they were like when Mark entered the field as you can gather have a few years on Mark and so I was there but I'm not going to be talking about my experiences but rather the situation that he entered because you've heard a great deal about how he has changed that facet of medicine the physician-patient encounter and relationship so allow me a few moments but before doing that let me say I first met Mark when I was the chairman of the Institute on Human Variousness in Medicine of the National Academy of Sciences as to internal medicine and also of the National Endowment for the Humanities and we had 77 fellows and I used to meet with those fellows from time to time I first met Mark in one of those meetings and immediately he impressed himself upon all of us with his imagination with his vigor with his sonorous voice with his takeover with his conversation and I say that in a very positive sense of the word Mark, you really did strike us as a promising physician for the future those of us who were old enough to have had a little bit of past but that program attracted very many young physicians 77 of them as a matter of fact and I would say that without making comparisons among those who profit at most from the basic idea behind that institute which was to provide an opportunity for a crossover between physicians, young physicians who were interested in the humanities specifically not so much ethics but the humanities and human values those are the two terms we use mostly in those days and with the humanists who were interested in medicine and what the program did was provide an opportunity in the summer for each to spend time in the other's purview and I think Mark you profited by that you brought a great to it a great deal to it but I think it provided a substance to what you were doing a support a notion that this might be something worthwhile and as Dr. Taloff said you were shocked by the choice of this particular pursuit in medicine and there were a number of young people at that time but they needed support and sustenance and I think the National Endowment for the Humanities should get some credit for that I didn't know what come out of Mark's interest it's been related to you in much greater detail than I can possibly do but I would like to suggest three of these which I think are most significant having worked in bioethics for a little bit of time one surely is the fellowship program and certainly the way to change a field is to train young people train young people and plant them in academic centers so they can be the viruses so to speak who would change the DNA of those particular institutions you have certainly changed the DNA to a certain extent I'm sure to put it very mildly here at Chicago but those you've taught have gone on around the country and have advanced the whole notion of the humanities in medicine out of which incidentally when the history is written the movement of medical ethics and teaching of medical ethics did grow a second most important aspect of Mark's work is grounding of clinical ethics in a firm conceptual and empirical foundation as I would say in a few moments and explain a little bit of how it was before Mark didn't do all of this I know he would agree with you but this was the kind of thing he would be dealing with and perceiving what was missing and the third is without any question the fact that while pursuing his scholarly work Mark continued to be a bona fide physician that is a source of verisimilitude a source of verification of what one is saying clinically that isn't always a part of the teaching of clinical ethics all these three actions on Mark's part played a role that's most unusual in changing our notions of what the clinical encounter was encounters a bad word but the relationship as I said between a peace person who was ill a time that comes when one is vulnerable dependent and anxious and that's what caught Mark's heart how do I bring contemporary medicine in that relationship let me turn then just a little bit to the then I asked Dr. Lanny Ross to tell me what she meant by then to interpret this rather freely so I did do so and I'm going to say a few words about how the clinical encounter was envisioned four or five years or more before you got into it namely in 1965 not to praise it please this is not an elderly gentleman telling you how great it was in those days not at all rather to tell you that the concept the perception of what it was to be with a physician and to meet a physician was different than it is today and to a certain extent that doesn't mean that everything that's changed is good or everything that is new is bad but only that we have had a continuation a continuous thread and it is with this thread of clinical medicine that Mark made his major contribution William Faulkner once said that the past is never dead indeed it's never past and that's the theme I'd like you to keep in your mind as I say a little bit about how it looked then America underwent a social revolution in the mid 1960s I'm not going to give you the history of that revolution but it challenged every received notion from the past religious, moral cultural within that was particularly a challenge to all received authority including professional authority before that occurred and that's what I'm going to be talking about that slice of time very, very quickly there was a more or less unified perspective in America on religious values, cultural values and so on and these were redefined because in the medical context they challenged really what it was to be a human being what it was to be ill what it was to have the experience of illness and what it was to be a healer in days past we could think in terms of the physician as a authoritarian father, a brother a friend as Seneca called him someone though who was at a distance from the patient who was empowered to make apodictic statements about what was right and what was wrong allegiance was expressed almost universally to the Hippocratic corpus and oath even though it wasn't practiced many of these things were not practiced but there was a general numbers of ideas and ideals which rested on the whole profession a different kind of relationship patients spoke of my doctor and doctor spoke of my patient a sense of mutuality that had a very great importance to both members the idea of the physician asking the patient what he would like or she would like to have done didn't exist the patient didn't understand how it could work in the first place he came to the doctor he thought to be helped now I'm not suggesting physicians faithfully followed all these ideals but it was the framework the social matrix within which that relationship was conducted some of us more certainly some others of us as well felt that this was something that had to change given the time that we were in a longer time when clinical decisions and professional relationships were dictated by long traditions of the past we entered an era in which everything was challenged including for physicians the revered Hippocratic oath remember now none of these statements are value statements on my part they're simply descriptions of where we were and one had to then think about how does one reconstruct the fidelity relationship the situation in which a patient is forced to trust in a physician patient relationship in which the power is on the side of the patient how does one deal with that more suggested the negotiated relationship especially professional ethics was situated within a communal agreement on certain things which ought not to be done this such things as the sharing and splitting of fees in fraction of the ethics of consultation conflicts of interest financial interest collusion with pharmaceutical companies crackpot panaceas association with persons of physician or in savory character those were things that defined the area what not ever to mention again this does not mean I want to insist on that fact there were not physicians who practiced all of these irregular and borderline activities what it does mean however that physicians did not justify those marginal practices somewhere somehow there had to be a foundation put into the relationship so that even if one did not share the same values with the patient with the society one could enter into a human relationship a relationship of equality of dual dignity I'm often asked to compare today's physicians and medical students with those of my time the 40s and people assume that physicians and students were better character and their personal ethics was of a higher order I am most emphatically opposed to that position medical students today as they have always been are biopsies of humanity of the American people with good and bad intermingles and it will always be that way but what the kind of movement that Mark has been involved and has done has to raise sensitivities raise sensitivities to the point that even those who were on this margin of things that were not entirely acceptable began to feel more and more uncomfortable about moving into those areas I think Mark would not want me to say that he has single-handedly changed all of this but all of his work as you can see his published work his work with his own students and residents above all his example which by the way is the only way to teach medical ethics by the example of a respected clinical teacher this is not to appreciate those who are not physicians please do not make that infancy that it's merely to say that we need some small category of persons who have a knowledge of medical ethics and also have a knowledge of the interstices of that relationship and I'll simply close by saying that Mark understood what interestingly a poet John Keats said about philosophy he said that axioms in philosophy do not become axioms until we feel them on our pulses and I think that as a teacher Mark what you have done has helped your students on their pulses the experience of the patient I close merely by saying that over and over again when I ask my patients what should I tell these young residents what is the most important message that I can give them and they say over and over and over again tell them please to feel something of our experience to feel that they're in our place the way I like to put it today is help your students to feel that they are on the gurney and that they're in the position of dependence and uncertainty and anxiety and that the physician the most important thing about the physician after his technical capability is his character and Mark that's the tribute that I would pray to you that your character your virtues as a human being and as a physician all the message that you have given thank you so we're going to fast forward and have Peter Singer talk about clinical ethics the field today and then at the end we'll have Dr. Pellegrino and Dr. Singer both take questions Peter Singer one of the co-organizers of the conference is a senior scientist and professor of medicine at the McLaughlin Rotman Center for Global Health at the University Health Network and University of Toronto Peter Singer is a member of the Scientific Advisory Board of the Bill and Melinda Gates Foundation Grand Challenges for Global Health Initiative a former member of the U.S. National Academies Committee which reported on globalization biosecurity in the future of life sciences and he has advised the U.N. Secretary of the Office on Biosecurity between 1995 and 2006 Peter was the Sunlight Financial Chair in Bioethics Director of the World Health Organization Collaborating Center for Bioethics at the University of Toronto and Director of the University of Toronto Joint Center for Bioethics Peter studied internal medicine at the University of Toronto Medical Ethics at the McLean Center for Clinical Medical Ethics at the University of Chicago University School Let us welcome Peter Singer Thank you very much it really is a great honor to be here and a great pleasure to be here with you Mark and all these people who admire and adore you so much it's great to be a part of it you know I was never a huge fan of tenure and I think after those stories we heard today I mean is that not the most compelling argument against tenure ones ever heard and the work that went into promotion and tenure was actually put to some productive use in any event today we're very happy here to be having a fest drift for Mark Siegler so just raise your hand if you know what the hell a fest drift is yeah so about a third of the people do you know one of the early originators of the idea here was Martin McNeely who's here in the audience and when he said to me I wasn't sure either I looked it up on the dictionary on the web and a fest drift turns out is a volume of articles essays etc. contributed by many authors in honor of a colleague usually published on the occasion of retirement are you retiring Mark? No okay or another important anniversary I guess the 25th anniversary or another important anniversary so I won't tell you about the other definition Miriam Websters which said they usually it was in memory of someone they clearly got it wrong on the other hand though on Wikipedia it tells us that one scholar actually said quote a fest drift frequently enough also serves as a convenient place in which those who are invited to contribute find a permanent resting place for their otherwise unpublishable or at least difficult to publish papers now keeping that in mind and keeping in mind the definition focused on this volume but with a penumbra of celebration around it what I would like to suggest is during these proceedings we focus a little bit more on the fest and a little bit less on the shrift I want to speak briefly about clinical ethics now and I've entitled my talk The Mark Siegler Effect and as anyone who has come even within 15 degrees of separation of Mark knows he's really a force of nature I just wanted to start before getting into a bit more substantive stuff with three early memories I was in the 1980s early 1980s a medical student really trying to find my way I was interested in both the clinical and scientific side and the humanistic side and I would say when I first read a legacy of Osler which was really along with Dr. Pellegrino's moment of clinical truth one of the two core inspirational pieces for physicians really changed my life I became very interested in this field before there really even was a field of clinical ethics I first met Mark in 1985 I distinctly remember a time we were driving along in Toronto and we were just discussing the opportunity for me to come here a year or so after that and I was really surprised at the time Mark started asking questions about my mother my girlfriend and of course what he was doing was looking to see how easy it would be to move and whether even for a year and whether someone is coming here or more opposite when people are leaving here anyone who has passed through here knows very much about Mark's personal involvement in recruitment and placement issues which I actually found extremely unusual and very endearing when we first came back to Toronto together we gave grand rounds together at one of the hospitals and that was actually also the first time I met my wife so in a sense Mark introduced me to my wife she was sitting in the audience Mark was giving a talk to someone who had done their internship with me and my wife leaned over and said what's he like and she said well you gotta stay away from him he's a jerk so Mark in summary for these and very many other reasons has really changed my life and that's the quickest way to summarize it but what I want you to reflect on is has he changed yours because I bet you for most people in the room and I'm sure some of these stories will come out after hearing those stories because I think in the long term I'll come back to this in a second that's a huge part of the legacy the influence you've had on people's lives Mark and for that we all thank you very very much now as many of you know Ed Pellegrino, Mark and I have a a decennial hobby that's every 10 years which is to survey the field of clinical ethics and two of the papers are in your booklet in the first issue of the Journal of Clinical Ethics and that reviewed the previous decade from 1980 to 1990 of clinical medical ethics and the second paper that I want to focus on in this talk was published in 2001 January so let's say very close to 2000 and it reviewed the second decade of clinical ethics and what we're talking about here is clinical ethics in 2010 and what I want to ask is maybe this is a warm up so maybe you guys want to think about we do this again in 2010 and what I'd like to ask everyone in the room is to please email me any thoughts or comments you have I'll share some early thoughts about the field but I'd be very interested in your thoughts and comments particularly where you think I get it wrong and there's my email address and you can raise hell in the discussion period or email me later and maybe we'll use this to feed into another one of these in 2010 so as you know those papers are divided into four parts research teaching, clinical ethics which we call ethics committees and consults and the future of clinical medical ethics and what I've done on the next eight slides is I've put what we had as the remaining challenges in 2001 on the first slide of a couplet and then some early reflections about the field on the second slide of a couplet which is really where I'd be looking for your input in 2001 we said that some remaining challenges were research in clinical ethics needed to become a mainstream concern for funding agencies that there was more evidence-based ethics research needed and less commentary that ethics journals had low impact and weren't read by health workers that more interdisciplinary and interprofessional research was needed and that capacity building in clinical ethics research was required now in terms of research in clinical ethics you do have some important papers I did a little search not as sophisticated as Lainey but actually the top-sided paper since 2000 has been this paper by Zeke Emanuel and colleagues on what makes clinical ethics what makes clinical research ethical with 340 citations which is getting into the mainstream of well-cited papers but not yet like a method like SDS polychrome electrophoresis ethics I think has moved into the funding and journal mainstream and there's lots of capacity for research there's lots of ethics groups with sort of millions of dollars of peer-reviewed funding lots of articles in mainstream journals that I think has been accomplished there are still 10 relatively low impact medical ethics journals but open access in terms of journals has made a big difference on distribution just as an example this revisited paper from 2001 I mentioned was the fourth most accessed paper ever in that journal with over 22,000 accesses so that's what open access has done really to journal publishing even in medical ethics I fear that we're at the same level of interdisciplinary and interprofessional research and there's still some stuff we can do there and there is still much more opinion than evidence in the corpus of medical ethics scholarship finally I'd like to say that there's not in my view a serious commitment to using research results to improve the patient experience and I just want to pose this as a hypothesis and I want to ask you what is the groundbreaking finding in the last 10 years in the field of clinical medical ethics that's been published that really has had major patient care implications and changed patient care to suggestion here but in other fields like cardiology or neurology you could point to two or three really groundbreaking things that have made major changes for patients and I think we're not quite there yet but I'd be interested in anyone's other views in the discussion in the area of teaching in 2001 we said the remaining challenges were internet-based teaching modules needed to increase dissemination of knowledge we talked about the incorporation of continuing health education continuing medical education effective practices including for bedside teaching we spoke of the need to harness the informal curriculum to develop an ethics focused culture we said that there ought to be more attention to character formation and role modeling which I think we also said 10 years before a greater focus on evaluation and a need to strengthen capacity to teach ethics especially at the bedside now in terms of teaching clinical ethics the hypothesis I want to share is there's lots of internet-based teaching and capacity building and this graph the slides that Laney showed are really the premium interperies example of that but I fear there's not been much progress on incorporating best practices of continuing health education character formation role modeling and in particular harnessing the informal curriculum to change the culture of medicine or evaluation of bedside ethics skills of students and physicians and I think that nexus of things which is all very closely related is the unfinished agenda and again very open to counter-factual examples that can be used to modify these tentative conclusions in terms of ethics committees and consults we said the remaining challenges were to integrate those functions into the quality improvement culture of health care organizations that need to develop accountability frameworks for ethics in health care organizations systematic strategies needed to be built for ethics capacity among staff in health care organizations we called for the further development of organizational ethics and the need to demonstrate that improvement in patients' outcomes were related to clinical ethics activity in a health care facility ethics committees and consults are clinical ethics now if you will has made a lot of progress just to start with the second point you know the accreditation standards in US and Canadian accreditation standards very heavily rely on ethics I'd ask if the best practices are being shared but there's been a lot of movement there quality and ethics though are still not fully aligned our mainstream ethics culture I fear especially beyond the walls of the McLean center is still critical and therefore not improvement oriented it's a lot easier to criticize something than to fix something and I fear that that's the prevailing and predominant culture of much of bioethics criticism is extremely important especially in scholarship don't get me wrong but there's also a need to roll up your sleeves work within institutions think that the perfect shouldn't be the enemy the good and fix the real patient care problems that you see and I think we're just the tipping point of that becoming the prevailing culture but I don't think we're there yet and I think that if and when we do get there a lot of the credit for that will go to the seeds mark that you sowed and that's so critically important for patients organizational ethics has developed there are some excellent systematic strategies developing for ethics and healthcare organizations like the VA like our own joint center and these are very well described by Sue by Ellen by others in the Cambridge textbook of bioethics in their chapter on health systems I think the main unfinished agenda though is something I'd like to call the Sue McCray agenda for about 10 years or 15 years or maybe 20 years Sue McCray who's also a graduate of the center has been arguing for integrating patient and family experience and narratives into clinical ethics and really using that as the intellectual backbone if you will of clinical ethics and using clinical ethics almost as a conduit to feed those real narratives back to healthcare workers I think there's some writing about that but I don't really think that that transformation has yet occurred and that I think is another piece of the unfinished agenda the future directions piece in 2001 we pointed to the main piece of unfinished business as being the inequities in global health and we said at that time in 2001 quote when we revisit clinical ethics a decade from now we hope to be telling you about the world health report on global health ethics written in 2006 the report will address important global issues in bioethics we went on to say beyond research ethics which had already been relatively well globalized in part and largely due to the efforts of Bob Levine and others who are here in the audience now though ethics has been globalized beyond research ethics there's a lot of stuff written in global health ethics and I was so pleased to hear about the initiative from Ann Dudley that you're launching sadly the inequities are the same or worse as the result of HIV and AIDS largely so if you just think about it the chance that one of your children will live the estimated life expectancy of one of your children is about 80 years and rising the estimated life expectancy in sub-Saharan Africa as a whole is 46 years and falling and there's a number of countries where it's in the 30s and if that isn't the mother of all ethical challenges I don't know what is so it's fantastic that we started seeing writing about it but I think Mark bringing the sort of transformational action that you've had in clinical ethics to that sphere will be extremely important so let me explore for a moment why we haven't made more progress about the inequities themselves maybe we just need more time on this agenda it takes a long time unfortunately to change things Bioethics has become the mainstream in politics not always for the good but sometimes for the good in the US but not elsewhere ethics needs to work better with other disciplines because the solutions are holistic and I think there's also an issue around the private sector the private sector matters and we probably should stop demonizing it as an ideological matter although there's often specific issues for criticism in public and private institutions so there's just some reflections and I'm going a bit out on a limb on some of them and I'm inviting any sort of pushback but I think that this still is the main piece of unfinished business for bioethics looking forward so what I've done is just very quickly tried to get an overview of clinical ethics now using the lens of what we wrote ten years ago updating it really with what is not much more than opinion and I really love it if that opinion could be vetted and become almost a type of collective opinion of this group through your pushing back or shaping or influencing any of those ideas and as I say maybe we can use that input that we get to do it again before either of you guys retire although I know that's probably pretty far off for both of you. I just want to end with a tribute to Mark and to Anna because of course and I'm sure we'll hear this a lot the influence of one's family not just Anna but all of your children Mark and your parents and so on the influence of one's family is extremely important in allowing one the time the space the energy and the support to do this and in Anna's case she actually helped in far more direct ways many many times. In doing this tribute I just want to reflect on what Mark's real legacy is is it the booklet full of ideas that you're so enthusiastically clutching in your hand in terms of his great papers is it this room full of wonderful and talented people just look for a moment to your left look for a moment to your right and just have a feel of what fantastic people in the room is it the field that's full of both these ideas and these people you know if you google clinical ethics you get 757,000 hits and the top entry is Mark's book clinical ethics if there were a Nobel Prize in ethics which of course there isn't the citation would read Mark Siegler created the field of clinical ethics so Mark on behalf of all of us and we'll have many chances I think to celebrate you I just want to say on behalf of all of us we thank you very very deeply and very very much thank you I think that's a really very good question thank you for it let me take a stab at it and then Dr. Pellegrino to respond to because Dr. Pellegrino really is the father allow me to say so bringing philosophical reflection deep foundational principles into the field of medical ethics so we may have slightly different views we'll have to find a balance but what I would say in response to your question is that I think what one needs is a balance you know if you search ethics articles you'll find that and I haven't done this lately but you'll find that about 90% of them are opinion and 10% of them are evidence I'm actually not arguing that 100% of them even 50% of them should be about evidence I just think one needs a slightly better balance and in fact one of the great things about clinical ethics is the opportunity to go back and forth from the normative world to the empirical world almost in terms of wide reflective equilibrium and so I think we're limited in terms of the base of evidence that we can go back and forth to and that's all I'm really saying not imposing an evidentiary standard on philosophical or legal scholarship or even opinion and commentary which is so important really just striking a balance to make that going back and forth between the normative world and the empirical world and more fulsome enterprise I don't know Dr. Pelgrino if you'd agree or disagree with that but this is your beg so far away well I agree in part but I do have a slight difference as you suggested I don't think that one suggested between the empirical and the conceptual is a real one I think you must have both in my own looking at the physician-patient interaction or encounter the moment of clinical truth there has to be a balance between the experience I touched on it briefly in my talk the experience of illness and the experience of healing and what it is to be someone who is ill that's often forgotten that doesn't mean that we shouldn't put the maximum effort we can into the technological dimensions of medicine but nonetheless in the long run we're talking about a human being going through a predicament and illness is a predicament so in my own approach to it I always start with the phenomena of illness and the phenomena of approaching a patient and the phenomena of offering oneself as a healer in that first moment of the relationship out of that I draw a concept so I believe you start with the empirical and then you reflect on it in a critical way and you expect from that what it is now that's a very classical and ancient way of thinking about things philosophically not very popular with many people today but I think if you reflect on it you cannot either derive a good notion of what it's about without looking at the experience nor can you universalize that experience unless you step back and reflect what is it, what makes it what it is what makes it different what makes clinical medicine a kind of human activity which has its own internal morality now that's a very very argumentative statement and not many people agree with me for it Bob? No but here comes the mic This works too? I want to ask Peter if he could tell us in his call for evidence that clinical ethics and its teaching and practice has a good effect on patient outcomes I would like to know how we could go about measuring that That's a really insightful question and I don't have a glib answer or an easy answer but this is a good opportunity to say when I'm talking about evidence and I know also this when Dr. Paul Green is talking about evidence we're not talking about quantitative clinical trials alone or quantitative research alone we're talking about the full spectrum of evidence from quantitative to qualitative research sociological studies narratives of experience and so on I think our views join I would just say by way of personal reflection I was trained as a quantitative clinical epidemiologist by Alvin Feinstein and I found over time I was doing more and more research using qualitative methods eventually settling on case studies now those case studies are pretty close to the narratives of clinical experience I was referring to in relationship to the sumacray agenda so it is a piece of research to find those narratives feed them back and judge the effect of this of those in an evaluation framework that valorizes and values soft what Alvin used to call soft or sociological or qualitative outcomes that's not a full answer to your question but it gives you a flavor of where I'm coming from and I also think probably where Dr. Pellegrino is coming from and I would just say that there's also on the other side gets back to your question a little bit as well you know you can cite examples of large scale expensive pieces of quantitative research in bioethics that didn't really help the field that much and you know for me and I'm sorry if I'm saying the wrong thing here the support study is not a bad example of that in some ways it was extremely important because it was a large randomized trial effort in end-of-life care and that was extremely important in some ways by looking primarily or only at quantitative outcomes that study found what you'd expect to find a negative trial because it wasn't looking for the right outcome so if you will pseudo-quantification can also backfire and sorry if I'm you know there's a lot of great things about the support study and it really is an iconic trial in medical ethics but I think there's also valid critique around the types of outcomes that were measured that's a relevant example to the discussion that we're having Bob wants to ask you a further question yeah well put not the limitations of the empirical approach of quantifying things that should have been dealt with more qualitatively I'll stop in a second Bill but I just want to add to it I agree with Peter's early response to you and I think some things simply are not measurable and positivistic terms and I think that's the dilemma and the delusion of scientism to apply the scientific method something is not susceptible to it Aristotle pointed that out a very long time ago so I think we need really to get a balance but there are forms of knowledge that we use that are not necessarily logical deductive I can't spend a lot of time on that now but a number of contemporary philosophers have gone that way with considerable productivity excuse me Bill Professor May but substituted the word conceptual you suggest that something more significant is going on yeah it's a very helpful comment thank you and it actually lets me qualify what I was saying and what I mean by opinion what I mean by opinion is not serious scholarship in philosophy and religion and law which has its own set of quality standards one wouldn't quite I don't know if one would call them evidentiary standards but certainly quality standards that's not what I mean by opinion what I mean by opinion and I referenced it in the sort of medline searches if you will of medical ethics in the medical literature is the commentary format something that might count as a commentary in Lancet a policy forum in science a sounding board in the New England Journal and you're very right and when we write this up we have to qualify what we mean by opinion now even those can at times be quite rigorous and philosophically informed one of the great examples present company excluded Professor May I won't cite your work which I think gives a lot of good examples of this as well but one of the great examples is the commentary written by Dennis Thompson that's if you will in the commentary opinion format but brought a serious philosophical framework to the exercise so in summary I'm not at all intending to be dismissive of serious scholarship in law and philosophy or any discipline with deep scholarly roots and strong intellectual standards what I'm really saying many of the clinical fellows here often do and you look at 90% of it is sounding board 10% of it is empirical evidence based quantitative or qualitative and I think that balance could change and by the way I think the balance on the opinion side could also shift a little bit more towards a more sophisticated blending of the philosophical legal and other normative approaches and religious studies approaches with the standard format of commentaries that don't always show what their fundamental scholarly base might be for their argument do you agree with that or disagree that's progress compared to where you started that's a good question so thank god that's a good diplomatic statement Bill I think he's but sincere well I'd like to just add on the matter of point opinion is a proposition it's the beginning of a dialectic it is not the conclusion and it is not necessarily one that has to be subjected to empirical evidence and there are a lot of things I think that's one of the problems we're having in medical ethics today is trying to emphasize what is not subjected to that possibility I want to just quote our startling he said that the educated man does not look for precision in an experience which does not render itself to that kind of examination so opinion is valid the beginning of dialectic what is the dialectic and carried out in a very orderly and systematic way which I think we're talking about yeah what he said thank you very much thank you Dr. Pellegrino and Singer