Meeting Transcript
December 2, 2004

The Stephen Decatur House
1610 H Street, NW
Washington, DC 20006

COUNCIL MEMBERS PRESENT

Leon R. Kass, M.D., Ph.D., Chairman
American Enterprise Institute

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

Francis Fukuyama, Ph.D.
Johns Hopkins University

Michael S. Gazzaniga, Ph.D.
Dartmouth College

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

Mary Ann Glendon, J.D., L.LM.
Harvard University

Alfonso Gómez-Lobo, Dr. phil.
Georgetown University

William B. Hurlbut, M.D.
Stanford University

Charles Krauthammer, M.D.
Syndicated Columnist

Peter A. Lawler, Ph.D.
Berry College

Paul McHugh, M.D.
Johns Hopkins University School of Medicine

Gilbert C. Meilaender, Ph.D.
Valparaiso University

Diana J. Schaub, Ph.D.
Loyola College

James Q. Wilson, Ph.D.
University of California, Los Angeles

INDEX

• Session 1: After the Life Cycle: The Moral Challenges of Later Life
  
• Session 2: Aging and Care-Giving: Options for Decision-Making
  
• Session 3: Aging and Care-Giving: Are there Objective Standards for Decision-Making in Caring for Patients with Dementia?
  
• Session 4: Biotechnology and Public Policy

WELCOME AND ANNNOUNCEMENTS

CHAIRMAN KASS:  Good morning.  Welcome to this, the 19th meeting of the President's Council on Bioethics.

I would like to recognize the presence of Yuval Levin, who is the designated federal officer, in whose presence this is a legally-constituted meeting.

Before coming to the program, I, with some sadness, have to announce that Dick Roblin, who is our Scientific Director, will be stepping down from that position at the end of this calendar year, a position that he has filled with consummate skill, grace, and devotion for the three years of the Council's existence.

When I was first appointed to this position, Dick, who was an old friend of now over 40 years from our graduate student days, expressed a willingness to interrupt his career plans for a year and to give me and us one year of service as the Scientific Director.  That one year has grown to three, involving heroic commuting, two daily 90-minute commutes from Frederick, and he has given all of us, and me in particular, the benefit of his extraordinary probity and judgment, his dependable penchant for care and precision, and his insistence that all of our work conform to the highest standards of scientific and other sorts of reasoning and evidence.  All parts of our reports, but especially the scientific parts, have benefitted immensely from his knowledge and critical acumen.

The only saving note of this is, I'm happy to add, that Dick has agreed to continue as a senior consultant on scientific matters to the staff, cutting down to a day or so a week.

Dick, all of us on the Council applaud your work and are deeply grateful for your outstanding service.

(Applause.)

This meeting is devoted to three subjects of ongoing interest to the Council:  ethical and social issues of an aging society, the regulation of the uses of biotechnology, and, with a novel twist, embryonic stem cell research.  The topics will come in that order.

Members will recognize these remarks from the Chairman's letter, but I would like to put them on the record.  After the last meeting in discussions with members of the Council, we identified at least three pieces of this aging and dementia topic that were ripe for possible Council reporting and recommendations.

First of all, an overview of the looming "crisis" in long-term care, to be presented in humanistic as well as medical and economic terms.

Second, an evaluation and critique of the growing reliance on advance directives as the primary means of dealing with critical decisions in the care of people incapable of making their own decisions.

And, third, a consideration of possible substantive ethical guidelines for deciding how vigorously to intervene medically in patients with advanced dementia.

These topics grow out of things that we have heard here beginning in April.

SESSION 1: AFTER THE LIFE CYCLE: THE MORAL CHALLENGES OF LATER LIFE

CHAIRMAN KASS: In this first session, we will be returning to a theme that was introduced to us in the June meeting by Thomas Cole, whom we welcome back to the Council.  Since we last saw him, Professor Cole has been appointed Professor and Director of the McGovern Center for Health, Humanities, and the Human Spirit at the University of Texas-Houston School of Medicine.

In June, Professor Cole presented a paper, "What Does It Mean to Grow Old?", richly illustrated with iconographic illustrations that illuminated the absence, in our time, of a clear cultural script for the meaning of old age, precisely at a time when most of us can expect to enjoy a fair stretch of it.

He raised for us really one of the very most fundamental questions, rarely asked and rarely discussed, which is to say, what is old age to be like in the New World?  Such questions — though they don't immediately lend themselves to specific policy recommendations, consideration of these questions, it seems to us, is crucial to thinking soundly and wisely about public policy.

As a result of conversations we had after that meeting, we have commissioned Professor Cole to develop further the ideas that emerged in the June discussion, and we look forward to hearing his presentation, giving us an overview of a paper, which you have at your place, newly arrived (at least an early draft of this paper), "After the Life Cycle:  The Moral Challenges of Later Life".

Before letting Professor Cole begin, I would also like to welcome Professor Carl Schneider, who is the Chauncey Stillman Professor of Ethics, Morality, and the Practice of Law at the Law School of the University of Michigan.  He will present in the second section.

Welcome to both of you.  It's nice to have you here.

Professor Cole, the floor is yours.

DR. COLE:  I very much appreciate the chance to return and to really, in particular, respond to a question that Bill Hurlbut asked at dinner when itwas too late to be coherent.  Basically, he asked, how should we be thinking about the moral and spiritual sources of inspiration in later life?  Here is an attempt, a first attempt, to think about that with you.

Here's just a quick overview of what I'll be covering.  After my introduction, I'm going to talk very briefly about the normativity of the life cycle.  I do this with some hesitation, knowing that people here have written elegantly about the normal and the natural and the moral.

Then I'll talk briefly about the modernization of the life cycle, basically, showing how we don't really have a life cycle anymore in our culture; what we have is a life course.  We really have a life course, not a life cycle.

Then I'll begin to get into the meat of what I've tried to think about, which are, what are the moral challenges that older people face, both people who are healthy and relatively physically intact, and those who are frail and unable to really carry out the activities of daily living?

In almost 30 years of reading and writing about later life, my favorite book is still a very slender volume by the Catholic theologian Henri Nouwen and a co-author named Walter Gaffney.  It's entitled, "Aging:  A Fulfillment of Life," written in 1974.  Like many books on aging written in the seventies and eighties, Nouwen really goes after negative stereotypes and attitudes toward older people.  He's trying to offer us images and ideals that emphasize solidarity, based on our shared humanity in the universal process of growing older.

The book's central motif if a large wagon-wheel leaning against a birch tree in the white snow, beautifully photographed.  The photo invites us each to think of ourselves as a spoke on the great wheel of life, part of the ongoing cycle of generations.  It implies that each of us has our own life cycle to traverse, a moving up and a going down, a moving forward, yet somehow also coming back to the beginning in relationship to generations before us and after us.

It resembles the Christ-centered circular life cycle from the medieval period which I showed last time that I was here.  But while medieval Christians considered earthly time as a mere shadow of eternity, the late 20th century Catholic theologian asserts that we have only one cycle to live and that living it is the source of our greatest joy.

Well, modern western culture, since the Reformation, has placed great emphasis on the affirmation of everyday life, on relief of suffering, and on the respect and dignity and rights of individuals.  So, as a modern, therefore, Nouwen sets the issue of a good life squarely in the province of everyday living.  He leans heavily on Erikson's work, which I will come to, and he writes that our greatest vocation is to live carefully and gracefully.  Aging then becomes the gradual fulfillment of the life cycle in which receiving matures in giving and living makes dying worthwhile.

With elegant simplicity, he describes a three-stage life cycle as it cogwheels with previous and future generations.  The restful accomplishment of the old wheel tells us the story of life.  Entering into the world, we are what we are given, and for many years thereafter, parents and grandparents, brothers and sisters, friends and lovers keep giving to us, some more, some less, some hesitantly, some generously.  When we can finally stand on our own feet, speak our own words, and express our own unique self in work and in love, we realize how much is given to us.

But while reaching the height of our cycle and saying, with a great sense of confidence, "I really am," we sense that to fulfill our life, we are now called to become parents and grandparents, brothers and sisters, teachers, friends, and lovers ourselves and to give to others, so that when we leave this world, we can be what we have given.

Now I must say I love the lyrical beauty of this passage and, in particular, its view that an individual's personal development naturally entails self-transcendence and moral responsibility in later life.  As he puts it, "receiving matures in giving."

But contemporary American culture seems to emphasize individual development without a clear consensus or even a rich debate about the meanings of later life and the responsibilities of older people to future generations.  With the rise of mass longevity and the ever-lengthening life expectancy, the roles, responsibilities, virtues, vices, and meanings of an extended life take on urgent meanings in both public and private life.

Strangely, there is almost nothing written on this topic.  There's a plethora of literature which focuses appropriately on the ethics of caregiving, on private and public responsibilities to older people, on the rights of older people, but there is virtually no discussion of the reciprocal responsibilities of older people.

In the bioethics literature, older people or their proxies are viewed solely as bearers of rights, as individuals entitled to make their own choices regarding health care, but there is precious little work on the content of those choices or on the larger issues of accountability, responsibility, virtue, and vice in later life.

So let me contextualize this issue with a brief interpretation of Nouwen and of Erikson, on whom he really basically relies, focusing on the normative dimension of their views of aging and the life cycle.  Then I'll offer an historical argument that we are living after the life cycle, both normatively and structurally.  Finally, I'll provide a tentative sketch of the moral challenges of later life for both healthy older people and those who are frail and sick.

Let me begin with a brief analysis of Nouwen's perspective and that of his more famous counterpart, Erik Erikson.  Philosophically, Nouwen's view rests on an ancient doctrine shared by Greeks, Romans, and Christians alike, that the human lifespan contains a single order, it's a natural order, and that each stage possesses its own characteristics and moral norms.  "Life's race course is fixed," wrote Cicero in De Senectute.  "Nature has only a single path, and that path is run but once, and to each stage of existence has been allotted its appropriate quality."

With the rise of Christianity, this normative life cycle is folded into a divinely-ordained natural order, and the stoic ideal of rational self-mastery is replaced with a journey to salvation.  Nouwen writes as a Catholic.  His view of the life cycle is couched mostly in secular psychological terms which echo Erikson's famous psychoanalytical formulation in the "Eight Ages of Man," each with its own cycle/social conflict and corresponding virtue.

First formulated in the mid-twentieth century, Erikson's version of the life cycle virtually dominated American academic thought and public imagination for over 25 years.  I think Erikson's theory is actually a restatement of the stoic ideal, supplemented by evolutionary and psychoanalytic theories.

Like the Stoics, Erikson argued that the cycle of life contained its own stages, each with their own moral norms and struggles.  He saw virtues as not as lofty ideals formulated by theologians and moralists, but rather as essential qualities rooted in human evolution.  As he put it, "Man's psychosocial survival is safeguarded only by vital virtues which develop in the interplay of successive and overlapping generations living together in organized settings."

I don't want to spend too much time on Erikson.  Most people are very familiar with him.  The key virtues that he emphasizes are integrity and experience which conveys some world order and spiritual sense, no matter how dearly paid for.  It is the acceptance of one's one and only life cycle as something that had to be and that, by necessity, permitted no substitutions.

Wisdom, therefore, is described as detached concern with life itself in the face of death itself.  It responds to the need of the oncoming generation for an integrated heritage and yet remains aware of the relativity of all knowledge.

Erikson understood that the life cycle itself does not biologically generate prescribed virtues, values, and behaviors associated with each stage.  Rather, every version of the normative life cycle is created by forces of biology, culture, demography, history, social structure, and patterns of family life.

Many of his followers, however, tended to treat the eight ages of man as if it were a universal paradigm of human development.  In my view, the model that developed through Erikson and used by Nouwen really should be understood as the culmination of the modern western life cycle ideal first imagined in early modern Europe and then fully realized in the middle third of the 20th century.

But the irony here is that modernization removed the traditional structural underpinning of the normative life cycle and replaced it with the life course.  So in both modern and post-modern society, old age emerges as an historically-unprecedented, marginal and culturally-unstable phase of life.

So herein lies the poignancy of our situation:  We are living after the life cycle, and in this context, Erikson's extensive life cycle writings take on an almost numinous quality.  They offer hope for an ideal of the life cycle we desperately want to believe in.

But however attractive, Erikson's ideal could not accommodate the social, cultural, and demographic complexities of our era.  We need a richer, pluralistic dialog about how to live the ever-lengthening years of our later life.

But, first, let me briefly sketch this historical context of our uncertainty about roles, responsibilities, purposes, and meanings.  I'm not going to go through each of these topics in any detail, but I basically want to make the point that the modern life course, as opposed to the ideal of a life cycle which is lived in a place in which generations after generations live together and cogwheel with each other, the modern life course begins in an urban, industrial society.  The older bonds of family and status and locality are really loosened, and individuals become increasingly encouraged to see their lives as careers, as sequences of expected positions in school, at work, and in retirement.

So by the third quarter of the 20th century, western democracies had pretty much institutionalized this life course by providing age-homogeneous schools for youthful preparation, jobs organized according to skills, experience, and seniority for middle-aged productivity, and publicly-funded retirement benefits for the aged who are considered too slow, too frail, or too old-fashioned to be productive.  This is often referred to as the three boxes of life:  education for youth, work for adulthood, retirement for old age.  And old age is then roughly divided into a period of active retirement, supported by Social Security and pensions, and a period of frailty supported, additionally, by Medicare, Medicaid, and private insurance.

So, again, the cycle of life becomes essentially severed from the course of life in modernity.  Again, when people lived in farms and villages, small towns, local traditions of practice and belief and behavior provided the external norms as each generation visibly cycled into the next, and the problem of identity did not arise.

But, as we've seen, this is really no longer the case in an urban, industrial, and now post-modern society.  As the British sociologist Anthony Giddens puts it, "The idea of a life cycle makes very little sense once the connections between an individual life and the interchanges of generations have been broken."

So, until the last quarter of the 20th century, this institutionalized life cycle which effectively had structurally and in some ways normatively undermined the cycle of life, it was fairly stable.  But, by the 1970s, what you found was an unraveling of this institutionalized life course, a powerful movement by older people and their advocates to overcome negative stereotypes of older people as inevitably frail and dependent.

Then in the eighties we saw a rebellion against the bureaucratized life course and against restrictive age norms.  Writers and scholars called for an age-irrelevant society that allowed more flexibility for moving in and out of school and the workforce.

At the same time, serious doubts about the proportion of the federal budget devoted to old people were voiced in the name of generational equity, as were fears of an unsupportable public obligation to sick and dependent older people.  As we've seen, political support for the welfare state began to erode.

So, finally, the problem of the transition to an information economy has made things even more culturally and psychologically unstable.  Amidst a globalizing economy, declining corporate commitment to long-term employment, to seniority, and defined pension benefits, there has been a steady erosion of the expectation of income stability in retirement.

Zygmunt Bauman characterizes the result of a speedup of life in the Information Age and the decline of long-term stability and benefits in the corporate life as resulting in kind of an ontological insecurity which is especially apt for older people.  He writes, "The boundaries which tend to be simultaneously most strongly desired and most acutely missed are those of a rightful and secure place in society, a place where the rules do not change overnight and without notice.  It's the widespread characteristic of men and women in our type of society that they live perpetually with the identity problem unresolved.  They suffer, one might say, from a chronic absence of resources with which they could build a truly solid and lasting identity, anchor it, and stop it from drifting."

So identity, then, is not merely a personal issue.  It has much broader social implications, and I believe it's crucial to the development of wisdom and to knowing one's responsibilities.

So how are we going to think about the moral life of older people after the life cycle?  Well, even Erikson realized early on that there's a basic problem built into sort of western ways of thinking about the life cycle.  In 1964 he wrote, "Our civilization does not really harbor a concept of the whole of life as do the civilizations of the east.  As our world images a one-way street to never-ending progress, interrupted only by small and big catastrophes, our lives are to be one-way streets to success and sudden oblivion."

So the absence of a culturally-viable life cycle set within a larger frame of transcendent meaning makes it difficult for many people to grasp possibilities of spiritual growth and moral purpose amidst physical decline.

In his seminal work, "After Virtue", Alasdair MacIntyre argues that we no longer possess a commonly-shared moral language and that, in a world of moral strangers, the only alternatives are Aristotle or Nietzsche, which means basically tradition or chaos.

So, by analogy, I think we're living after the life cycle, after the collapse of widely-shared images and socially-cohesive experiences of the life cycle.  But I do not think that we are forced to choose between idealized tradition on the one hand or exaggerated chaos on the other.

First of all, the lack of a scholarly literature or articulated norms does not imply that most older people are leading morally-incoherent lives.  And, secondly, the very search for identity itself I think holds important moral promise.

So here I'm going to briefly just draw on the work of Charles Taylor, who believes that, despite the moral limitations of liberal individualism, the Biblical tradition he believes lives on as a kind of underground moral resource in most lives, and for Taylor selfhood or identity is inextricably bound up with some historically-specific but often unarticulated view of the good.

So for Taylor, then, the attempt to be authentic need not degenerate into self-indulgence and motivism or moral relativism.  He thinks that a person in search of identity always exists within a horizon of important questions which transcend the self.  Attempts at self-definition and self-fulfillment that ignore questions and demands outside the self suppress the very conditions of meaning and purpose.  As he writes, "Only if I exist in a world in which history or the demands of nature or the needs of my fellow human beings or the duties of citizenship or the call of God, or something else of this order, crucially matters, can I define an identity for myself that is not trivial."

So my point here is that we should not view the search for identity in old age as a narrowly-personal quest.  Of course, we're all familiar with examples of late-life Narcissism, but the effort to live an authentic life is itself a moral ideal, an attempt to understand and fulfill the uniqueness of each life.  Older people trying to make sense of their past and imagine their futures through various forms of life review, spiritual autobiography, reminiscence, storytelling, life story writing groups, and so on, these people are doing important moral and spiritual work with genuine implications for others.  Those who are passionately involved in the arts, in public service, and in new forms of exploration begin to exemplify models of elderhood.  As Erikson puts it at the end of "Childhood and Society", "Without elders who possess integrity and identity, children will be unable to trust."

So authenticity, basically, by itself is not going to be able to provide standards of conduct and character to guide moral development in later life.  Authenticity provides no reasons to restrain the person who authentically chooses selfishness or evil, and it contains no intrinsic norms or prohibition.

Perhaps the dominant ideal of later life today is what the Austrian sociologist Leopold Rosenmayr calls "Die Späte Freiheit," "the late freedom."  Free from social obligations, retirement for those who possess good health and adequate income is equated with leisure activities:  visiting family and friends, golf, mahjong, bridge, travel, taking up new hobbies, attending classes at elder hostel, institutes for learning in retirement, visiting family and friends.

The problem here is not that these activities are wrong or bad, but they are based on the concept of "freedom from," freedom from obligations that we have at midlife, with little or no attention paid to what the freedom is for, which principles or commitment should guide the choices being made.

Today senior marketing and advertising specialists have, I think, the primary influence on activities, programs, and products for seniors looking for ways to spend their free time.  And maintaining one's health is the primary goal spurred on, I think, by the commodification of the body.

So the next real ideal after authenticity and freedom seems to be the ideal of health, and, of course, services, products, and programs for healthy aging are probably the most lucrative segment of the senior market.  Health is becoming increasingly construed as physical functioning that's divorced from any reference to meaning or human purpose.  The reduction of health to physical functioning fits hand-in-glove with the notice of freedom as unfettered choice.  Let me give you an example.

In the 1970s, the biologist Alex Comfort wrote two popular books, The Joy of Sex and The Good Age.  Comfort celebrated in both of these books technique, functioning, achievement.  Well, in the early eighties, I invited Comfort to participate in a Conference on Aging and Meaning, which, by the way, is the Conference where Bill May gave his prescient paper on the virtues and vices of aging.  In a letter he wrote back to me, he bluntly declined to participate on the grounds that he had no interest in "grannyology."

Well, this response I think reveals the obvious disdain for older people, single-minded focus on control and functioning, and a common but rarely articulated discomfort or contempt for existential concerns that underlies most discussions of successful aging today.

More specifically, by linking sex with age and achievement, Comfort anticipated the contemporary redefinition of sexual decline and impotence — these are things which occur in individuals — into treatable sexual dysfunctions which occur in organs; again, another way in which medicalization has separated the images and ideals of illness and disease from actual people.

I think one of our options here is to try to reclaim the notion of health suggested by the AAMC.  "Health is not just the absence of disease, but it's a state of well-being that includes a sense that life has purpose and meaning."

So, given the limitations of authenticity, of individual freedom, and of health as adequate ideals, how should we begin to explore the moral challenges of aging?  Ronald Blythe offers this penetrating, if harsh, starting point, which Bill May also used in his essay.  "Perhaps with full lifespans the norm, people may need to learn how to become aged as they once learned to be adult.  It may soon be necessary and legitimate to criticize the long years of vapidity in which a healthy elderly person does little more than eat and play bingo or who consumes excessive amounts of drugs or who expects a self-indulgent stupidity to go unchecked.  Just as the old should be convinced that whatever happens during senescence, they will never suffer exclusion, so they should understand that age does not exempt them from being despicable.  To fall into purposelessness is to fall out of real consideration."

Now that sounds harsh, but, actually, his interviews with older English people both in the countryside and the city was incredibly humane and wonderful.  That's a wonderful book which is not judgmental about older people.

So the point here, I think, is that learning to grow old is, indeed, an important concern in our aging society, and it calls for human development policies.  We need job retraining, creative use of leisure time, lifelong learnings, stimulation of volunteer networks and self-help groups.  These kinds of things help people develop the skills and the strengths to solve their own problems.

As Harry Moody has pointed out, aging policy that responds only to problems intensifies the depreciation of the strengths and capacities of older people and may inadvertently increase the tendency rather than try to prevent it.  Falling into purposelessness is not only a matter of individual will and character, but it's also a matter of culture and public policy.  Old people, like all people, they need to be needed.

Well, in approaching the moral challenges of aging from the point of view of the aging person, I've really always appreciated Rabbi Hillel's ancient three questions:  "If I am not for myself, who will be for me?  If I am only for myself, what am I?  If not now, when?"

I take each of these questions to stand for a phase of the life cycle, harkening backs to Nouwen's formulation.  As children and adolescents, there's a natural tendency to see the world as one's oyster.  In midlife we realize that to mature we must attend to the needs of others, and in later life, with time running out, we must learn how to balance our needs against the interests and needs of others.

Interestingly, whereas Nouwen speaks only of giving as we age, Hillel speaks of balancing competing needs and interests.  So if we take Hillel's questions and apply them to later life, I think we can begin to specify key questions which demand careful and balanced responses.

As citizens, what responsibilities do we have to our community and the larger society, to the poor and the vulnerable, to our communities of faith?  How do we balance these against our personal interests?  What are our responsibilities to our children and grandchildren for caregiving, for economic support?  Again, how do we balance these against our own needs and interests?

What responsibilities do we have for older parents who may be in their eighties, nineties, or even a hundred?  And, again, how do we balance these with our own personal interests and well-being?

What responsibilities do we have to future generations to help safeguard the environment, to work for sustainable sources of energy?  What responsibilities do we have for a spouse who is permanently disabled perhaps by the later stages of dementia?  Can we say, as some people do, "This isn't the person I married and I need to live my own life," or do we owe a degree of loyalty that includes daily visits and ongoing care?

Recently, you may have seen the movie and read the book "The Notebook" by — I'm blocking on his name.  Anyway, it's a love story in which it goes back and forth between the present with a severely-demented wife and her husband and the past when they first fell in love.  It's based on a continuing daily visiting which ends in somewhat sentimental but actually quite beautiful restatement of their love.

What responsibilities do we have to shoulder, depending on circumstances, part of the burden of our own economic support?  What responsibilities do we have for our own health, for exercising prudence in our use of health care responsibilities?  What responsibilities do nursing home patients and residents have to assist each other?  What responsibilities do we have to pursue a path of continued growth and spiritual development which aims at self-transcendence, compassion, commitment to others, acceptance of physical and mental decline, and preparation for death?

I'm not going to attempt to answer these questions.  I want to raise them.  I believe they are urgent and that they call for personal wrestling, public debate, academic inquiry, and perhaps some kinds of public policies.

If we look, for example, carefully at advice literature about aging over the years, we could really see a whole lot about changing values and norms that are conveyed to a reading public of older people.  We need a great deal of social and behavioral study of what older people think about these issues as well as how they act.  We need studies of the moral and spiritual lives of older people in various geographic, ethnic, racial, gender, and class situations.  We need diverse religious reflections and their translation into practical programs and congregational life.  We need philosophical inquiry and public conversation, and we need to listen carefully to the stories of both ordinary and exemplary older people.

I don't think we can expect universally-true, decontextualized norms and values to which all elders should be held accountable.  In a pluralist society, we need to hear from various religious, ethnic, racial, and political groups.  We need to hear, for example, from the AARP, which some people think has actually sold out to the market an enthusiasm of the young-old and is always perceived as a powerful lobbying group on the part of older people.

We need new ideals.  We need new models.  One example is the Spiritual Eldering Project that was initiated by Rabbi Zalman Schacter and sponsors a series of workshops around the country for older people who would like to become real elders in a sense of becoming mentors, in a sense of becoming devoted increasingly to the environment and to the communities that they live in.

There's a civic engagement project currently undertaken in the Gerontological Society where Marc Freedman, for example, has long been working on strengthening voluntary movements of older people, offering their care and their skills with underprivileged urban youth.

But I think we need to step back from some of these more normative applied ethics kinds of questions and recognize the complexity and the nuance that's required to grapple with these moral questions.  John C. Powys' wonderful book on the art of aging ("The Art of Growing Old") writes, "If by the time we're 60 we haven't learned what a knot of paradox and contradiction life is, and how exquisitely the good and the bad are mingled in every action we take, and what a compromising hostess our Lady of Truth is, we haven't grown old to much purpose."

In other words, we need to strive for wisdom and spiritual development to help us understand and respond to the moral challenges of aging.  As Powys points out, life is a "knot of paradox and contradictions."

So what are the paradoxes and contradictions one faces on the way to wisdom?  And, of course, one is always on the way; one is never there.

Well, one prominent paradox is that wise people know that they don't know.  They tolerate uncertainty because they understand the limits of any attempt to grasp the entire truth, especially their own attempts, and they understand the need for multiple points of view.  As Florida Scott Maxwell put it, "I cannot speak the truth until I have contradicted myself."

Wise people cultivate habits of self-examination and self-awareness.  They do not attempt to impose their will on the world, but learn to observe and accept reality as it is, and acceptance changes reality.

Consider the paradox that loss is gain, failed expectations are a precondition for acquiring experience which reflection may turn to growth, or the paradox that, unless a person accepts her own limited subjectivity and the way she projects herself onto the world, she will be unable to work on transcending these things.  Likewise, a person who understands and accepts the transitory illusions of their self-image are then able to go onto a higher level of understanding themselves.

Now these paradoxes and contradictions are not solvable problems.  They must be worked with by each individual in search of spiritual growth, but, of course, this does not happen without guidance and without community.

So our society, therefore, needs to support a variety of contemplative practices, including, for example, prayer, meditation, self-reflection, yoga, tai chi, and so on.  So here we have, again, the ancient problem of the active versus the contemplative life, another contradiction which needs revisiting.

And one of the most important and difficult paradoxes of aging is physical decline and spiritual growth.  How can we learn to work hard maintaining our physical health while at the same time preparing for our own decline and death?  How do we learn to hold on and let go at the same time?

One of the central obstacles to wrestling with the challenges of old age lies in the intractable hostility that America has towards physical decline, decay, and dependence.  Rather than acknowledge these harsh realities, we pretend that we can master them, and we feel like failures when we don't.

So let me turn, then, to moral and spiritual aspects of dependency.  Dependency raises a special range of challenges for older people.  There are no guidelines for how to be a good, dependent person, and I doubt that such guidelines would be a worthwhile goal.

Hence, we must enter first into dependency's innerworkings before we can understand its moral challenges.  Imagine a life in which you cannot walk, cannot carry out your accustomed activities of daily living.  Perhaps you're blind, demented, or incontinent, a world in which you must wait for others to bathe you, take you to the grocery store or to the doctor.  Time stretches before you like a desert.  Shame and self-loathing lacerate for the loss of your independence.  You're tempted to both false displays of self-sufficiency and to letting yourself go completely, lapsing into pure passivity.  Family relationships become strained, especially when caregivers and receivers of care are dutiful playing their proper roles without acknowledging their own and each other's emotional turmoil.

Wendy Lustbader has a lovely book called Counting on Kindness:  The Dilemmas of Dependency.  She makes here an unusual point about mercy.  The old word "merci" originally meant compassion and forbearance toward a person in one's power.  In Latin, "merces" signified payment or reward, referring to aspects of commerce.

"Mercy," writes Lustbader, "is entirely based on exchange.  Giving help eventually embitters us unless we are compensated at least by appreciation.  Accepting help degrades us unless we are convinced that our helpers are getting something in return."

As much as we might prefer to reject this stark accounting, we discover in living through situations of dependence that goodwill is not enough.  A delicate balance exists at the heart of mercy.  Reciprocation replenishes both the spirit of the helper and the person who is being helped.

We seem to lack language to acknowledge the difficulty of receiving.  Hence, the dependent person may feel doubly burdened, disliking the help that cannot be repaid and feeling guilty for the dislike.  Increasing frailty shrinks opportunity to be useful, eliminating external obligations.  No one expects our presence and no one needs our efforts.

Finding ways to be useful requires imagination and will power; for example, among nursing home patients who often figure out ways to help each other.  Feeling useful will sometimes require special sensitivity of the caregiver.

As a geriatric social worker and therapist, Wendy Lustbader spent many years going to the homes of frail elders who were ashamed of their needs and struggled to conceal them.  She once visited a woman who allowed her in because of a sudden illness.  The woman's lightbulbs had burned out.  She was reading by daylight and sitting alone in the dark.  The woman refused to allow Lustbader to stand on a stool to change her lightbulbs.  Lustbader said she hated thinking of the woman unable to sleep, tossing fitfully in her bed and unable to read.

At last, the woman's pride relented and Lustbader changed the bulbs.  "As I left, I thanked her for giving me the honor of helping her."  She understood what I meant, for it was she who was carrying the burden of uselessness and I who was being granted satisfaction.

The next section that I had planned to talk about is the section on virtues and vices.  I think I will skip over most of this because it's provided by the readings that you have from William May and Sara Ruddick, who come at this from very different points of view.

But just let me say, despite an extensive literature research in English, these are the only two articles I was able to find on the virtues and vices of dependent older people.  And I think I would like to offer a couple of words of caution before going into this because I think this is a very dangerous, politically and morally, topic.

For example, friends on my left are going to argue that I'm singling out the elderly for judgment, and friends on my right are going to use moral arguments for responsibility of older people to dismantle necessary state support.  So I want to just sort of say I'm in neither of those camps.

So I think any full exploration of virtues and vices must take into account differences in culture, gender, race, ethnicity, and social class.  And contrary to Cicero's exclusive emphasis on character, exercising virtue is not simply a matter of individual will.  Virtues occur amidst social conditions and relationships which foster or inhibit them.

A given person's capacity for exercising virtue, especially the more subtle and demanding virtues, also depends on her prior level of emotional and spiritual development.  For example, for some people simply carrying out the thou shalts and the thou shalt nots of our society may be a more reasonable expectation than expecting them to be exemplary elders.

So, again, rather than spend time talking about these two essays, which you can read for yourself, I'm going to move on to what I think are the limitations of this kind of analysis and then on to some concluding thoughts, so that there will be some time for conversation.

The one thing I want to say, however, is the importance of humor as a virtue.  Bill May touches on this in his discussion of "hilaritas."  He says, "Humor is a saving grace, allowed by the capacity to see life's experience from a more spacious perspective."

I remember George Burns, who was performing in his nineties, who before he got started, he said, "I want to ask for applause in advance."

(Laughter.)

So, without trying to compare or contrast May and Ruddick or see what they have in common, I just want to ask, what can we expect from the analysis of character and action among the frail elderly?  And, again, these are issues for the future.

What's missing from these accounts?  Can we educate caregivers on the importance of acknowledging reciprocity and fostering relationships which allow their patients to be useful?  What would relationships look like if moral language and the reciprocity of dependent patients was introduced into geriatric and gerontological education and into nursing homes or home care?  How can we educate clergy, both in the pulpit and at the bedside, in the moral challenges of aging?

Seminaries have only recently begun to provide some gerontological education for their students, but they focus entirely on the needs of older people.  What should be added to revitalize religious understanding of older people as moral agents?

And, finally, with the proliferation of lifelong learning through elder hostels, institutes for learning in retirement, could older people themselves be engaged in seminars, workshops, about the moral issues in their lives?  I'm fairly skeptical about this latter idea since in my experience older people are notoriously absent when you offer a course in aging.  That's something that they don't want to know about.

(Laughter.)

But I think that the use of Biblical material, films, fiction, theater might slip by their defenses and open up new moral and spiritual horizons.  Think of old King Saul or King David, King Lear, "Oedipus at Colonus," or "Driving Miss Daisy," or "Cocoon" or "A Trip to Bountiful," if these were examined through the lenses of ethics and the human spirit.

So where do these thoughts about life-cycle norms, mass longevity, post-maturity, moral obligation, spiritual development, and virtues and vices leave us?  Where, personally, I feel a sense of awe and amazement at the sheer abundance of life made possible by the gift of mass longevity, but what is the price of that gift?  I think that's an open question and it's a political question in part.

Perhaps, as Theodore Roszak argues in America the Wise, the wisdom of a maturing population promises to be our greatest resource.  I suspect he's overly optimistic, just the way he was when he wrote The Greening of America back in the 1970s.

Perhaps, on the other hand, education and policy will make no difference whatsoever, and in that case we might think, as the Talmud suggests, that a man who is a fool in his youth is also a fool in his old age, while a man who is wise in his youth is also wise in his old age.  I suspect that the truth between these points of view is going to depend on how well we learn to identify, support, and accomplish the moral and spiritual work of aging in our era.

As Plato understood in The Republic, one of the best ways to learn is by listening to those who have traveled this road ahead of us.  So let me close by listening again to one of my favorite elders, Florida Scott Maxwell.  If you don't know her slender volume, The Measure of My Days, I strongly encourage you to take a look at it.

She's writing in her eighties, mid-eighties.  She's very frail, and she's writing from the perspective of a Jungian analyst.  She encourages us to learn that life is a tragic mystery.  She writes, "We are pierced and driven by laws we only half understand.  We find that the lesson we learn again and again is that of heroic helplessness.  Some uncomprehended law holds us at the point of contradiction where we have no choice, where we do not like that which we love, where good and bad are inseparable partners to tell apart, and where we, broken-hearted and ecstatic, can only resolve the conflict by blindly taking it into our hearts.  This used to be called being in the hands of God.  Has anyone any better words to describe it?"

Thank you.

(Applause.)

CHAIRMAN KASS:  Thank you very much, Professor Cole.

The floor is open for the discussion of this paper.

Gil Meilaender.

PROF. MEILAENDER:  Thank you.  There's a lot there that I agree with, but it will be interesting if I ask you a question about something that I'm unsure about.

DR. COLE:  Sure.

DR. HANSON:  And it has to do with this notion of the late freedom that you discussed, and discussed as a problem in a way, the sense that we think of our lives as moving toward a freedom that's simply a "freedom from" rather than a "freedom for" something.

I'm always bothered when — and I'll grant this may just be a defect of character, but I'm always bothered when I learn that I have an obligation to continue to grow indefinitely — (laughter) — and that I need lifelong learning, things like that, since I sort of await the day when I can stop worrying about learning.

I wonder if you don't do sufficient justice to that "freedom from" idea.  I mean it is a "freedom for."  As you described it after all, it's a period of life when one worries less about being productive and more about certain relationships with family and friends, and so forth.  Those are great goods in human life, which we might well set over against the good of being productive and think that they are at least as important.  To find that I am given the gift of a time in life when they can take a kind of priority doesn't seem to me to be necessarily something to worry about, but something to be appreciated.

So I wonder if you could just say a little more about what you take to be the problem here, whether there's any truth to the caveat that I've tried to articulate, and just reflect a little more on that notion of the late freedom.

DR. COLE:  Sure.  I think that's a very good question, and I agree with the spirit of it.

I think there's a great deal of good in the late freedom, and it's a freedom we may be increasingly losing as we find that older people are being forced by economic circumstances to retire and go back to work to make ends meet, but I think it's there for a significant portion of the population.  And I think people choose to do wonderful things with it.

A level of volunteering, for example, that people with free time have is pretty impressive.  It ranges pretty much, for people 65 and over, it ranges about 25 percent of people choose to volunteer in some kind of public service.  It's usually in a church situation or religious situation, and they tend to give about 96 hours a year.

They choose to spend time with their children and their grandchildren.  They choose to spend time to read.  And these are all good things.

But I think the late freedom is not a complete idea because I think we do need guidance, more general guidance, and efforts to create ways of understanding our place in a cycle of generations, so that we use our freedom in ways that benefit the next generation.

I've read one theologian recently who argues that the primary obligation of older people is to show the next generation how to die, which is an interesting sort of point of view.  It is more a pre-modern point of view than a contemporary point of view.

So I think it's an appropriate caveat, and I certainly choose to use my late freedom, if I'm lucky enough to get it, to enjoy the hill country in Texas, where we have some land, and it's a beautiful area.  I just want to be there.  I just want to spend time there.

On the other hand, I really have in my mind — and my wife and I were talking about this —  I really have in my mind questions about how much of our resources we ought to put into building a house out there and, as Dan knows, clearing cedar and taking care of the raw land, which in many ways will bring back the native grasses and bring back wildlife, and so on.

How much resources should we put into that versus establishing trust funds for our grandchildren?  So if we put a thousand dollars a year in a trust for each of our grandchildren, by the time they're 18, with any luck, most of their college expenses will be paid.  And what about siblings who have not flourished, but who may need help when they get older because they don't have adequate savings?

So, again, it is a question of balance.  My hope is that we can explore the late freedom culturally, personally, and publicly in a more thoughtful way, and especially in ways that are not manipulated by consumer society, which wants to tell us how to buy our health, how to buy potence, how to buy health and happiness, and so on.

Anyway, I won't go on there, except to say I accept the caveat and appreciate it because I certainly don't want to come across as somebody who thinks that the late freedom is a bad thing.  I just think we need more reflection on what it's for.

CHAIRMAN KASS:  Mary Ann, and then Mike, and then Paul.

PROF. GLENDON:  I want to thank you for coming back.  I know that when I look back on these years on the Bioethics Council, I'm going to think of your two presentations as among the high points.

I can't find much to disagree with.  There is something I hope that one of your sources is wrong about, and that is the idea that, if you were a fool in your youth, you have to be a fool in your old age.

(Laughter.)

But what I wanted to ask you about, it's not so much a question as to ask you to say a little bit more about the political implications of those very interesting questions you raise on, I think it's pages 14 and 15 of your paper.  You stressed two things overall, it seems to me.  One is that we're living in an unprecedented situation, and the other is that the past toward coping with the challenges lies in attending to relationships and context.

So here's the problem, I think, when you're trying to imagine what a group like ours might be able to contribute, some of the things that make the situation unprecedented, the greatly increased need for long-term care on the part of so many people suddenly, and at the same time the sharp drop in the availability of paid or unpaid caretakers.

If you could just peer into your crystal ball a little bit, what do you think a group like ours might be able to do to set better conditions for coping with those challenges?

DR. COLE:  Thanks for that question and thanks for the compliment.

I think one thing that can be recommended is the development of human development policies to strengthen people's ability to solve their own problems, to be less dependent, because most of our policies are aimed at solving problems, and appropriately so, but I think there's much that can be done to educate, enhance, give incentives for people to become more independent and more self-sufficient in ways that are gratifying to themselves.

But, of course, the downside of emphasizing that is that I in no way want to add to the current tendency to begin to dismantle the welfare state, and especially Social Security and Medicare.  We know that half of the people who are supported by Medicare would be impoverished without it.  We know that, as you said, long-term care is a looming crisis both in terms of funding and in terms of availability of caregivers.

So that's why I have so much trepidation really in raising these issues.  I guess I would say, from a political point of view, that it's very important to develop awareness and political support for taking care of the most vulnerable, which is a sort of primary principle, and not blaming people.  There is a tendency to blame people for their dependency.

In the 19th century, for example, during a health reform craze, Alexander Graham, who developed Graham crackers, was in a frenzy of health reform, which is kind of the predecessor to health promotion today.  He said, if people were sick, it was because they were not leading good lives, and that if Methuselah, he said if Methuselah had arthritis, it was his own fault, and Methuselah lived to 969 years.  So encouraged commitment of resources and development of community participation in caring for the vulnerable and the needy I think it absolutely essential.

One thing that I've seen in terms of older people volunteering their time, there are some networks around the country in which people sign up as part of a group.  I think this takes place in San Antonio.  When they volunteer their time to deliver Meals on Wheels, to look in on somebody who's house-bound, to help clean, or whatever, their hours are clocked.  They clock their hours over the years, and then when they become dependent, they're entitled at least to the number of hours that they have put in, which is an interesting kind of idea.  So there's an attempt.

CHAIRMAN KASS:  Mike Gazzaniga.  You're first and then Paul.

DR. GAZZANIGA:  This is maybe just a reference that will bridge these two talks this morning.  There's an ongoing, three-year study that has been sponsored by the National Institute on Aging, a report that will be put together by the National Academy of Science on the social implications of people in an aging community.  People are showing growing interest in the nature of the mentation of older people and how that impacts the decisions that they are making in their professions and in their personal social life.

The good news is that, actually, as we age, we get happier.  One of the reasons we get happier is we ignore negative information.

(Laughter.)

So the actually great body of research that has gone on, to give you an example of it, you show older people a series of pictures, some of which are horrendously objectionable and some very pleasant pictures, and you subsequently test their memory of the two classes of pictures, and they have no memory of the objectional pictures and only of the bucolic ones.  So the point being then that — I kind of feel this myself (laughter) — just getting happier and happier, and so, therefore, maybe I should be removed from certain tough decisions because I ignore or deny the tough data that might make you want to modify your position.

But, anyway, there's a large report that will certainly be of interest to this committee, and to others, coming out on these topics.

DR. COLE:  Yes, I think that's very interesting.  I'm not aware of that.

But I am aware of studies that show in people who are considered old-old that there seems to be a decline in the functioning of frontal lobe brain work, and the implication there is important for ideas about autonomy because I'm not scientifically versed enough to be able to give you the specifics, but when these frontal lobe disorders take place, older people are less able to take initiative and pursue their choices and a course of action.  They're more vulnerable to being influenced by others than they would have been if this functioning was in place, which is an interesting finding, I think, and yet another problem for the idea of autonomy in bioethics.

CHAIRMAN KASS:  Paul McHugh.

DR. McHUGH:  I, too, very much enjoyed your talk, and it's wonderful to see you back here.

But I'm following on from a number of the comments already made in relationship to how to understand and give more teeth perhaps to the process of development that you have, I think, happily said has transformed itself from the cycle idea to the stages idea of life.  I've always felt that the cycle idea was pointless.  It didn't talk about the fact that people went through development and learned things and lost things in the process, and that was the natural reason for there being stages.

So when I hear you talk a lot about Erikson and the like, I have to tell you I have a visceral aversion to Erikson.

(Laughter.)

I'm not quite sure where it comes from, but I think partly it comes from the fact that he was embedded in the Harvard of the 1950s and 1960s where I was embedded, too, and he accepted the commitments and virtues of that place at that time and didn't wonder about stronger virtues.

In fact, part of the difficulty in much of our writing about elderly people and the way we should think about them does emphasize the softer virtues rather than the vigorous virtues, a distinction that I draw from a brilliant woman, Shirley Letwin, who said, we can have both those virtues; you can be both courageous and compassionate; you can both be faithful and nonjudgmental; you can be critical in your judgment and kind, too.

That kind of sense of who we are and how we develop, and how at each stage the vigorous virtues have to be emphasized and given, well, to some extent, given authority, I think falls away often in discussions such as we're having today.  So that's the first thing.  Bill and you both do touch upon the vigorous virtues, but perhaps, in my opinion, not emphasize them enough.

The second thing is that there are reasons why young people have certain responsibilities and older people have other responsibilities.  This was brought home just a couple of days ago when I was listening to a woman who had been embedded with our marines in the Fallujah campaign, and she came to realize that, boy, you've got to be 19 or 20 to go in there and knock down a wall.  She was following after them and she got very foot sore.  She was very brave, I thought, to be with them, of course, and it was wonderful that she was there.  I saluted her for that.  I also salute her for the fact that she realized that hardy and robust youth have these tasks and are ready for them in ways that 40- and 50-year-old people are not.  But that's to emphasize the humorous side.

Perhaps the issue that I want to see emphasized here is what Mike is saying in part.  There are reasons why we are asked to give up certain tasks that we're doing in our lives.  For example, anyone who is going to run a corporation, a department, an organization of any sort needs physical energy; he needs vision, but he also very much needs the capacity to fight entropy.  Everything is always falling apart.  Let me tell you, fighting entropy is an exercise that you weary of in the sense that it begins to fill your week, and you begin to shy away from it.

In fact, to some extent, what Mike is saying is absolutely right:  The reason why old executives need to be replaced is that they have stopped looking at the problems that they need to fight and are accepting them as part of benevolent vision that they have.  You've got to get rid of them.

The Dean and I agreed that, when I reached a certain age, it was time for me to step down as Director, and it did, then, allow me, because I no longer had to fight so much entropy except my own entropy, to emphasize my interest in the vision side of my discipline, and the like, to write more, to think more, to spend time with bright young people, and older people, too, to develop that.

So I missed two things in your wonderful demonstration.  I missed the emphasis on the vigorous virtues and I missed the idea that, in contrast to what Erikson says and this soft stuff, the "open sesame" school of human development (laughter), that's the humorous side.  My mother said I would go far if I forgot that side but didn't emphasize it.

(Laughter.)

Nonetheless, there are reasons why hardy and robust youth have to be the ones that go into Fallujah; middle-aged folks, educated and powerfully developed and things, need to run organizations.  And, finally, and it's best to take an age somebody should step down if that organization is going to flourish in the future with new people who can fight the entropy that the old have permitted.

CHAIRMAN KASS:  Some of us, those of us who have senior cards, resemble that remark, Paul, but never mind.

DR. McHUGH:  There's truth in it, though, Leon.

CHAIRMAN KASS:  Oh, I was joking.

(Laughter.)

DR. COLE:  Let me try to respond to those comments which were eloquently put, and I would like to read the source of the woman who wrote about the stronger virtues and the weaker virtues.

But, first, let me say something that I couldn't find any way to say in the paper, so I'll say it here.  My favorite definition of virtue is Jonathan Edwards' definition of true virtue.  It comes from a book he wrote late in life, when he was beginning to think in more aesthetic terms than purely theological terms.

He said, true virtue is absolute love of God and benevolence towards being in general.  I have never heard a statement about the highest virtue that inspires me any more than that does.  Now that's not an answer to any of your questions at all.  It was just a chance to say something I wanted to say.

I should have listed as one of my questions, when do people have a responsibility to step aside?  That's a key issue, and for different reasons.

One, because they may not have the capacity to fight entropy, and the other because they may be holding back the development of people who need to put their stamp on things and have a limited amount of time.

If I understand you right, I think there's a contradiction between your first question and your second question.  In other words, you want to hear more about the vigorous virtues and I need to know more about what they are to understand them, but you also make the point that older executives have a declining capacity to fight entropy in their organizations and in themselves, which would suggest that they don't have vigorous virtues.  That's one of the reasons why they need to step aside.  So I may be missing something there, but it looks to me like there's a contradiction in those comments.

Finally, let me say that I think what you're pointing to here is the difficulty our culture has in making room enough for the contemplative life.  We are a "can-do" society.  We want to get things done.  We don't much respect, although we're seeing a resurgence of this, we don't much respect the virtues of contemplation, of self-reflection, of quiet study, prayer, meditation, the kinds of things which have the capacity, I think, to help people grow quieter, calmer, and more benevolent, even though I understand that Gil Meilaender doesn't really want to have to develop any more because he just wants to be left alone; I feel that way myself sometimes, too.  But, anyway, that's an attempt to respond.

DR. McHUGH:  Let me just respond by saying I see how you could see those two questions as being contradicting one another, and it does depend on what I mean by the vigorous virtues.  The vigorous virtues include things like courage, self-reliance, fidelity, and critical judgment.  Amongst them, of course, would come the recognition that certain powers do decline in that manner, and just as one doesn't try to necessarily join in the same vigorous physical activities with hardy and robust youth when you're in your seventies, so at the same time I think you can have courage and vigor and vision and at the same time say this is an appropriate time for another person to take over the running of this matter because fighting entropy may be not only something that you begin to shy away from after you've been doing it for a number of years, and knowing what the fight is about, but also that you may not even recognize the ways that the corporation is failing, and it needs these younger people who have vigor of a physical kind and a vision that's complementary but perhaps expanded on yours; they need to have a chance.

Those are the things.

DR. COLE:  Thanks.

CHAIRMAN KASS:  But thank you very much for your comments.

Let me make a suggestion.  We're at the place we were scheduled to break.  We started a little late.  There's still three people in the cue.  If you don't mind, let's take the three comments and then you would respond to them in one piece, if you wouldn't mind.

I have myself, Peter, and Dan, Dan Foster.

It seems to me that, agreeing with all that Paul has said about responsibility of stepping aside and those things, the brunt of your talk really wasn't about that question as much as it was about what life should be like for people who have stepped aside and what one can reasonably expect from them.

I like very much the emphasis in the paper that authenticity and indeterminate freedom, or even the preoccupation with health, are somehow, while desirable in themselves, are insufficient because they are relatively content-free in terms of what healthy, authentic freedom should be used for, so that life is somehow fulfilling.

I mean, I'm seduced by the paper and the sort of idea of life that informs it, but — and this may be another one of these paradoxes that is simply ours to struggle with — but it seems to me in a world that's after virtue, it seems to me increasingly difficult to begin to talk about the virtues of those who are past their prime and to somehow begin to talk the language of the virtues that one should expect from them or try to cultivate them in a community in which the language of virtue has ceased to be the coin of the real, but where we talk about rights or various things of that sort.  So that would be the first point.

And that's made even worse by the fact that, in answer to Mary Ann's question and nervous about contributing to blaming the infirmed for their infirmities or trying welfare programs, you continued to emphasize the neediness rather than the aspects of the humanity of the old, other than their neediness, which is precisely the problem that we have fallen into.  I mean, to treat the elderly as either actual or soon-to-be objects of need and care is to cultivate a certain kind of condescension toward them and the community as a whole; whereas, what we really want to do is to remember the older you get, the more you realize what an injustice you have committed against the elders in previous ages, when you realize that from the inside they're still the same person they always were, at least until the very end.

So, to the extent to which we somehow think that what we have to do is promote the vision of care and the vision of neediness, we are in ways undermining the very kind of thing that you're trying to achieve here.

Lastly, it's just kind of a riff on this same point:  If, on the other hand, you are emphasizing the need to enable people to solve their own problems, to be more independent and self-sufficient, you're getting in the way of the kind of nice dialect about receiving with which the paper ended.  That is, on the one hand, you want to say to the old, "Well, don't be objects of need and care.  Be independent.  Learn to develop.  Learn to grow," and do all these sorts of things.  That makes it much more difficult to acknowledge exactly what is true of life as a whole, but especially in old age, that one of the gifts we have to those who are our descendants is we provide them with the opportunity, in fact, to care and to establish those bonds that really are enriching.

Now I don't expect you to solve those paradoxes.  I maybe simply caught the point of the talk.  But these are just things that are prompted both by the talk itself and the way in which you've proceeded to respond to previous questioners.

I then have Peter.  If it gets too much, just interrupt, but let's take Peter and then Dan, and if you can hold comment until the end.

DR. LAWLER:  Mass longevity is not so much a gift, but a deliberate project of human beings to overcome the life cycle or biological constraints.  The goal of this effort to overcome these biological constraints really is freedom from necessity, and this "freedom from" is especially enjoyed today by the old.  So the question is, what is this "freedom from" for, and the answer was given very properly by Gil.  It was for family, friends, and you added contemplation.  That makes good sense.

But the problem is the process that won us this "freedom from" is bound to be somewhat bad for families, friends, and contemplation.  This is a problem.  This is a paradox.  This is the downside of the upside of the great victory which has brought us mass longevity.

This is good to know because we can avoid this in our own cases.  During our productive years we shouldn't be so productive that we're not virtuous enough, so that when we get old, we don't have family, friends, or the ability to contemplate.

Maybe it will be proper for our Council to highlight this problem, so that many Americans can avoid this.  Nonetheless, I don't know of any government policy that could solve this problem or even alleviate the downside of mass longevity.

So it seems to me the government policies you pointed to had nothing to do with the problem you raised, which was a very good problem to raise.

Thanks.

CHAIRMAN KASS:  Dan Foster.

DR. FOSTER:  Well, I was going to say more, but let me just say two things.  Another interesting conflict that Peter hinted at right here is that in much of the world today the essential problem is to get an aging population — if you look in southern Africa, the life expectancy because of AIDS is 40 years.  If you look in the developed countries, we may have a solution to the aged in the long run because the birth rate has gone down dramatically in the developing countries which are there.

You could solve the problem of the aging in this country if you dismantle Medicare, and so forth, because they would die.  The best health insurance in the world is to not keep people alive, you know, to do that.  So you could have a correction simply by saying, well, okay, we're not going to treat people.

But the other side of that is that where the birth rate is high and where disease is not overwhelming, most of the children are coming out of resources and out of parents who don't have the opportunities to develop in a sense.  So what is happening is — and it's, I think, happening, will happen in our country and every place where there are lot of immigrants who have come from places that they can't help, but they don't have the opportunities to do things, is that you're going to have a big increase in the population without the resources to do it.

So my only point is that in much of the world the problem is that people are dying way too early, and there's a huge moral consequence that we have treatable diseases that we can't do anything from a humanity standpoint, but if you want to solve the problem of too old a population, then you just let that go.

And I would say one other sentence and then I'm through.  Because all of you know that I work in a teaching hospital that takes care of the poor.  Much of what we've talked about today is applicable to the healthy aging, as people have talked about.  Then you might think of moral things.

Survival is what we talk about every day, just survival.  We have more re-admissions to the hospital for congestive heart failure than you should possibly have, just because the people, even with Medicare, can't get their drugs, and a huge number of persons in Dallas, Texas don't even have Medicaid or Medicare.  So you get them in the hospital, get them out of their congestive heart failure; two weeks later they're back in — survival.

I mean most of the people that I see that are aged would not understand one single word of what we're talking about here.  They're talking about mere survival, and to be a recipient and understand all the arguments for reciprocity, and so forth — anyway, there are a lot of other things I could say, but I do think it's an interesting paradox for humanity as a whole, what to do about life expectancy, whether that's a good thing or a bad thing.

I think a 40-year life expectancy, whether it's in certain neighborhoods in Washington, D.C., because of drug murders, and so forth, or anywhere else, or Dallas, or an AIDS epidemic that's out of this world — and then, of course, we also, with all the wars that are going on all over the world, we also have wiping out the elderly, too.

CHAIRMAN KASS:  Please, as you wish.

DR. COLE:  Okay.  Thanks for those questions.  I'm not sure I got precisely every point in each comment.  So maybe during lunch we can pick up some of these conversations.

DR. FOSTER:  May I interrupt to say don't comment on whatever — I don't have to have any comments on anything.

DR. COLE:  I think there were some real interesting points I would like to respond to there.

One of Leon's questions was, where does the language come from that helps us understand what life should be like for people who have stepped aside?  One of the things I need, I think we need — and, actually, there's an enormous research agenda in this area.  One of the things that the committee could do is suggest the importance of setting aside funding to study these issues because it's not there.  It's very, very hard in the National Institute on Aging for humanistic and even social science, qualitative social science projects to be funded.

I think that the language will come from the people.  The language will not be in our theoretical ideas.  I think it will be an ordinary language, which is why I think we need studies of how people construe this, even in impoverished, especially in impoverished situations.  Because the woman who comes in for congestive heart failure and keeps bouncing back in, and is only seemingly concerned about survival, when she goes back to her home, she may have grandchildren living with her.  She may be in a church environment.  She may have a world view and a world order, independent of the health care, that helps her make sense of things.

So studying the language, I mean listening to different communities of older people and how they articulate their relationships to their churches, to their families, I think we would find an enormous amount of strength, moral strength, in ordinary life and from ordinary people, which then could become raised up as exemplary.

On the question of my seeming to emphasize the neediness of dependent elders, which seems to undercut the idea of their responsibilities, I think it's very important to begin to try to think about reciprocity, the need for people who are dependent, are necessarily dependent, either on their children or people who come in for home care or in nursing schools, these people need to be needed, too.  Finding ways, however subtle, to allow these people to reciprocate, and this can happen in genuine relationships that get started — this is part of Wendy Lustbader's point in her book The Kindness of Strangers — is one answer to this, by respecting the fact that these people are not just the demented patient or COPD patient on a certain floor, but have a whole life, and it's possible for that life to become intertwined with the lives of others who might like the stories, who might like the relationships, and caregivers.

On the issue, Peter's issue of mass longevity being a goal of human effort, I think that's a good point.  That's the Baconian project.  That's clearly what modern medicine has been after.

And you're right that the downside of mass longevity is something we hadn't anticipated, just the way we didn't anticipate that, once we were able to cure infectious disease and create public health conditions that allowed people to live, so their lifespan went from, life expectancy went from 40 to 75, we didn't anticipate the emergence of chronic disease and the debilitation that would come from those added years.

I don't think that means that in either case we shouldn't embrace and look for the possibilities in those experiences, and we shouldn't shirk our responsibilities for caring for people who suffer from those conditions, but I think we should also find ways to encourage people to take care of themselves and to know that it really makes a difference.

Compliance rates for so many things among patients is notoriously low, and I know it's a continuing problem for physicians and people who work in hospitals to have people bouncing back because they're just not doing what they need to do to take care of themselves.

I don't think I have much more to say in response to Peter's comment, except I would like to learn more about it.

And the last thing is in response to Dan's comments.  My understanding is that, except for southern Africa and Russia, life expectancy is growing almost everywhere else in ways that we would not have anticipated, we would not have expected.  It represents a serious crisis because those countries, those states, in the developing world do not have welfare states in place, do not have resources set aside to care for declining elders.

A couple of years ago, I was on a committee for the U.N.'s attempt to conceptualize aging during the International Year of the Older Person.  One of the things that that committee was working on with this in mind was to reformulate the image of aging in these countries and in our own country, so that older people became understood as resources, as people with potential to give, and wouldn't be seen just as people to marginalize and set aside, because that is going to be one of the only ways that these countries are going to be able to allow their older people to flourish, is if there can be ways for people to understand and cultivate their abilities to mentor, to keep contributing, to be useful.

So that's my response.

CHAIRMAN KASS:  Thank you very much, Tom, for a very rich discussion.  You have given us lots and lots to think about.

We are about 20 minutes behind.  That means I'm going to try to hold you to a 15-minute break, and we'll reconvene at five after promptly.

Thank you.

(Whereupon, the foregoing matter went off the record at 10:48 a.m. and went back on the record at 11:10 a.m.)

SESSION 2: AGING AND CARE-GIVING: OPTIONS FOR DECISION-MAKING

CHAIRMAN KASS:  During the break, Judy Crawford has left at our place the information regarding dinner for those who are joining us.  "I" Street is one street north, and the way to get there is to walk to "I" and just head west.  We will meet there at 6:30, just in case I don't remember in the afternoon session.  The little gray cells are not what they used to be.

This second session actually will pick up on themes that were at the very end of Tom Cole's paper, where he discussed questions of independence and dependency.  It's a great pleasure for me to again welcome Carl Schneider, who brings to this subject of medical decisionmaking the perspective not just of an autonomous autonomist, but a whole career of teaching family law, among other things.  I think that and the fact that he has a kind of muscular way of thinking and writing, which I very much admire — I appreciated these papers that you sent us very much.

We've had discussions in here before about the advance directive as one way to deal with the problem of decisionmaking for those who are incapable of making decisions for themselves, and Dr. Schneider has kindly agreed to lay out for us some of the alternatives, the strengths and weaknesses, and help us advance our own thinking on this subject.

So welcome again, and the floor is yours.

PROF. SCHNEIDER:  Thank you.  It's very kind of you to have me here, particularly since you don't need me; you have Rebecca Dresser, who is as important and useful an authority on this subject as the country has to offer.  It's a particular pleasure for me to be here because I know and esteem so many of the people on the commission and their work.

Perhaps I should say a word about myself so that you will know from whence I come.  First of all, I am a lawyer, not a doctor, although I have an appointment at our medical school.  This always confuses people.  You know that I'm not a doctor because I do not have slides for you.

(Laughter.)

I work in the part of bioethics that you have generally been ignoring, and that is the part that deals with the ethics of medical decisions in various forms, the doctrine of informed consent, various sorts of attempts at advance directives, end-of-life decisionmaking generally, physician-assisted suicide; those sorts of questions are the kinds of questions that you seem to be approaching and that I have been dealing with.

I am not just a lawyer, but an empiricist.  I plan to provide you not so much with information about what I think, which should not be very interesting to you, but information about how the world works, which ought to be very interesting to you.

The kind of empirical information I will be drawing on starts with medical studies.  One of the wonderful things about doctors is they often seem to care how the world actually functions and they study it.  I have tried to read, as systematically as possible, the medical literature that deals with the ways decisions are actually made.  I've spent a good deal of time doing research among doctors and patients, observing and interviewing them.

There is another source of data that I have found that's quite wonderful.  In the United States today there is a kind of cultural taboo against being seriously ill and not writing a book about it.

(Laughter.)

There are literally hundreds of these books, and many of them are wonderful.  They are wonderful sources of information and they're wonderful stories about people.  I have consistently found both this reading and my research among patients genuinely inspiring.

I confess that I have been puzzled about how to be most useful to you.  I have assigned readings in the usual way, but I am also aware from a quarter of a century of teaching that readings are not always read.  So I could just repeat orally what I have said in writing.

Mr. Levin's letter to me was Caesarean in its ambitions.  Leon Kass' suggestions to me were equally ambitious although rather different.   I tried to find solace and guidance by reading your transcripts, and as soon as I finished one transcript, I discovered it was contradicted by the next transcript, at least insofar as it was giving me guidance about what you might be trying to attempt.

So what I have decided to try to do was to speak to you in the sadness of experience.  The sadness of experience is that your predecessors in interests, as we lawyers like to say, other commissions and bioethicists, have over the last several decades provided the country with a series of bioethical programs.  The doctrine of informed consent is certainly one, new standards for research ethics, the Patient Self Determination Act, ideas for encouraging organ donation, and the like.

It is a fair generalization that these bioethical reforms have consistently failed to achieve the ambitions that their proponents had for them — consistently failed to achieve those ambitions.

And what I want to do is to talk a little bit about what we know about how medical decisions are made, how decisions for incompetent patients are made and might be made, drawing again on the kind of empirical research that I've been describing, and to try to talk very briefly then about what lessons you might learn from the failure of your predecessors.

Everything turns on informed consent.  Everything turns on the ability of competent patients successfully to make contemporaneous medical decisions.

The evidence is that they do not make medical decisions, even after a full generation now of informed consent, in the way that the proponents of informed consent, the way that earlier presidential commissions imagined would happen.

First, doctors do not provide patients with the kind of information that bioethicists supposed they would.  One recent study suggests that only in 9 percent of the many interactions between doctor and patient that these researchers observed, only 9 percent of those cases were patients given the kind of information they would need to make an intelligent medical decision.

Second, patients do not understand and remember what they are told.  Now why this surprises people is a mystery to me because so many of us here are teachers, right, and what do we do every semester?  We read the blue books.  And what does that tell us?  It tells us that what we said so lucidly and so often was not understood, that even the work of regurgitating simple facts is not done successfully by students who are specially picked for their skill at studying the areas you are teaching.

(Laughter.)

If that is true, a fortiori, as we lawyers like to say, even more strongly must it be true that patients, a completely random sample of the population, will not fully grasp and understand what they are told and, indeed, they do not.

One of the areas where decisionmaking has been best studied and where most efforts have been made to promote good decisionmaking is in the area of the treatment of breast cancer.  One study asked women who were interested primarily, they said, in survival, what difference there was in the survival rates of the treatments they were considering, and only 40 percent of these women answered correctly.  This was after they had consulted on average 5.5 sources of information.  Worse, of the women who said that recurrence was their greatest concern in making the decision, only 20 percent correctly recited even a rough rate of recurrence.

So not enough information is given.  Not enough information is understood.

Third, these problems cannot be solved in the ways that people have imagined or in any way that I can imagine.  These problems do not exist simply because doctors don't try hard enough and patients don't try hard enough.  No amount of fiddling is going to change this.  Let me give you a few reasons.

Let me say right upfront here that I am not describing one class of patients in general and myself as a distinction.  Many of my best insights into the foolishness and incomprehension of patients' decisions come from introspection.

I recently had the gout.  I formally consulted two physicians and was informally volunteered information, including one 20-page printout from WebMD, from three other physicians.  They all had completely different suggestions to make, all in terms of complete confidence.  I read the 20-page printout.  I listened to their advice, and I still don't know what I should do.  I don't even know whose advice to follow; I respect them all.

(Laughter.)

PROF. GLENDON:  Ask Dan Foster.

PROF. SCHNEIDER:  Please don't.  Please don't.  I have reached the point of information overload on this question.

(Laughter.)

CHAIRMAN KASS:  It's not a question of information; this is accurate.

(Laughter.)

PROF. SCHNEIDER:  Ah, I'm glad to hear it.

And this isn't a particularly complicated decision.  I mean people have had gout since, we know, the 18th century.  By the way, it is not caused by drinking too much port.

Where do the problems arise then?  Some of the problems arise from the fact that the literacy of the American population is quite low.  About 45 million people, or roughly one-quarter of the American population, are functionally illiterate.  Another 50 million are only marginally literate.  This means that in one study 42 percent of the patients could not understand the directions about taking medicine on an empty stomach when they were written down.  Many patients cannot read the appointment cards that they are given.  Many patients cannot read the cards that tell them how to get to the next office down the hall.

Many intelligent people just like us have tried for many years to solve this problem by writing simpler and simpler kinds of instructions.  One recent and sophisticated attempt to do so tried to provide prostate cancer patients with information about their choices.  When this project was finished, the authors conceded that it could not be read by half the population.

I have said nothing about the problems of mathematics.  These problems are at least as severe.  One of the standard tests of your numeracy, if that is actually a word, suggests that, asked three very simple questions, only 16 percent of the population got all three answers right.  Questions like, 10 is what percent of a thousand?

This works itself out in actual medical decisions in disturbing ways.  After being given data about risk reduction from mammography, from 7 to 33 percent of the women given the information, depending on how they were given it, estimated the benefit of mammography correctly.

But let's suppose all of these problems vanished, that we have patients with perfect information and perfect understanding.  Will that solve all of the problems that patients have in making decisions?  The answer is no.

And one reason that the answer is no is because what bioethicists generally assume is that patients come to decisions with a coherent and well-worked-out set of values relevant to the questions before them.  They do not.  Most people have better things to do with their lives than working out the kinds of values that you might need for making unanticipated medical decisions or even anticipated ones.

And, in fact, what psychologists who study these things tell us is that we do not make decisions by consulting our values, reasoning from them, and then doing what the reasoning tells us.  Rather, our values tend to be explanations that we give for the decisions we make and not the motives for the decisions themselves.  This is one reason that so often people make very inconsistent kinds of choices.

But let's suppose away not just the problem of information, but also the problem of values.  Would we then make good decisions?  The answer is no again.  The answer is no again because, in order to make a good decision about the future, we have to predict how we're going to react to the possible results that we might reach in the future.

And there is a very interesting body of research that psychologists gracelessly call hedonic forecasting.  Are people able to predict what is going to make them happy?  Well, now you would think that nothing would be more important to human beings than thinking about and being able to predict what's going to make them happy in the future.  People are spectacularly bad at it.

People grossly overestimate, for example, the intensity of emotions they will feel in the future and, not least, the duration of emotions that they will feel in the future.  This is why, when you've spent all of that money to buy an Audi, it did not give you $59,000 worth of satisfaction.  The satisfaction peaks the moment you drive out of the showroom and declines very precipitously thereafter, just like the price.  And there's a reason that the price goes down that fast.

Furthermore, people make these mistakes in ways that are especially relevant to medical decisions.  There are some interesting studies, for example, of people who recently have become quadriplegic or paraplegic.  They tend to picture for themselves a very, very bleak future, and, indeed, some people are suicidal, have some suicidal thoughts on receipt of the information.

That is because, among other things, what they are doing is they are saying, here is a datum; I am paralyzed.  How is that fact going to make my life worse?  What they do not say to themselves is, what are all of the things in life that I value and that give me satisfaction, and which of those things will I still be able to do, and how will my psychological immune system try to create ways in which I can be happy even given this fact?

And there was a famous study which very roughly goes like this:  You take people who have recently become lottery winners and people who have recently become paralyzed.  The lottery winners' happiness shoots up precipitously; the paralyzed people's happiness shoots down precipitously.  After a year, they have essentially returned to what some psychologists think of as their happiness setpoints.

But nobody thinks that that's what he's going to do when these things happen.  People do not predict their own future happiness very accurately.

Now part of what's going on here is that, in fact, it's true that experience is in many ways the best teacher, and experience often counsels us to reconsider our opinions.  People these days routinely recite the mantra that the quality of life is more important than the quantity of life, and they believe it up to the point at which the quantity of life actually becomes an issue, at which point they become remarkably unwilling to give up increments of quantity in order to get fairly large increments of quality.  There are some very interesting studies of this.  People who are very ill think that their lives are much more satisfactory than observers of their lives think.

There's a wonderful book by Wilfrid Sheed on his experience with depression and cancer and polio, and I think drug addiction.  He said he quickly learned that cancer, even more than polio, has a disarming way of bargaining downward, beginning with your whole estate, and then letting you keep the game warden's cottage or the badminton court, and by the time that it has frightened you to death and threatened to take away your very existence, you would be amazed at how little you're willing to settle for.

This is true, but when people are making decisions, this is not what they imagine themselves thinking.  But let's suppose all of these problems of information and values and psychological insight, let's suppose those problems all away.  Then can patients make good decisions?  And the answer is, you'll be surprised to hear, still no, and that is because people then have to go through quite an arduous process of reasoning about which means will best serve their ends.

That is something that people seem not to do very well.  There are many reasons for this.  One of them is that we all, in thinking about all kinds of problems, rely on what psychologists like to call various kinds of heuristics, shortcuts in our thinking that make reasoning easier for us.  These shortcuts actually turn out to work pretty well in situations with which we are familiar, but when we move into unfamiliar territory, these heuristics often serve us very badly.

We have a tendency, for example, to interpret all data as confirming our earlier opinions.  There are fascinating studies of people listening to presidential debates, and they invariably conclude that the debate confirmed the wisdom of their earlier opinions and the choice of candidate on the substantive issues.

People have a very hard time in keeping vivid information from completely overwhelming dry information, which is why stories about "my aunt who had this problem" invariably overwhelm more systematic and reliable statistics

But the problem is not these rather mechanical kind of heuristics alone.  Let me tell you about a study in which I briefly participated or in which I participated but in which somebody else did an awful lot of the work.

A physician and I went around to randomly-selected males in Ann Arbor and we said, "Doctors can't decide whether you ought to be screened for prostate cancer.  So what they have done is to defer the decision to you.  You're supposed to decide whether you want to be screened.  Here are all the data that you need in order to decide whether you should be screened, and we were willing to spend as much as an hour and a half talking with these men about whether they wanted to be PSA screened or not, leaving quite aside the question of just how many physicians in this world are going to have the time to spend an hour and a half chatting with the patient about PSA screening.

We worked very hard to be sure that we had solved the information problem, and then we would say, "So do you want to be screened?"  And they would say yes or no.  Either answer, of course, is acceptable.

But then we would say, "Why do you want to be screened?"  And he would say, "Well, I believe that prevention is always better than trying to cure something, and so I want to be screened."  Now it is true that it is better to prevent a disease than to try to treat it, by and large, but it is not true that PSA screening prevents diseases.

The difficulty here was that they were really latching onto an important idea that did apply to cancer in many sorts of circumstances, just not this one.  But we would never have found out that they didn't understand that they were using a wrong heuristic had we not been doing research and had the time to schmooze with them about the nature of their reasoning.

But this was a situation where people went through their reasoning fairly carefully.  What I have learned from the studies is that, by and large, people tend to make medical decisions with an alacrity that precludes thought.

(Laughter.)

It is literally true that people make decisions on the spot a very high percentage of the time.  I have observed people being given choices about modality of dialysis at some length, and this is a caricature but captures the truth.  The informer would start, "We're very sorry to have to tell you, but your kidneys are failing and you're going to need some kind of substitute for them.  We have a couple of things to offer you."

Their first thing is called hemodialysis.  Now with hemodialysis, we take two large needles, at which point the patient says, "Needles?  I'll take the other one.  What is that?"

(Laughter.)

But sometimes they would listen placidly through the needles part and would get to the part where we started to talk about peritoneal dialysis which involves implanting a tube.  "Implanting a tube," they said, "would it show in the summer when I was wearing a bathing suit," or I suppose these days when you were just wearing clothes.

(Laughter.)

And the physician would say, "Well, yes, it will."  "I'll take the other one.  What was that other one?  Oh, yes, the one with the needles, I'll take that."

Now this is, first of all, happening at a speed that makes it clear that people have not really assimilated and thought about all the information that may be relevant.  In fact, one of the questions that people never asked and were never provided was data on the relative morbidity and mortality of the different kinds of dialysis.

Now what is clear is that a significant number of the people who make decisions are fastening onto a single factor and making that the sole basis for their decision.  Sometimes that's not a bad thing to do, but with difficult medical decisions this is often a reckless way of going about making decisions.

Another way that we know something about the process that people go through in making medical decisions is that, when we ask the people who write the kinds of books I've been describing, first of all, they almost never describe making medical decisions.  I started reading these books in the hopes of writing a book on how people made medical decisions, and I couldn't do it because the data did not permit me to talk about that.

When they did talk about it, they talked about it in terms like this:  "I've learned to listen to my inner voice for guidance when choosing treatments.  If I get a ding" — parentheses, a strong instinct — "about a vitamin, herb, drug, or other treatment, I try it."

Lest you think that this person was not one of us, a sociologist at Rice describes his experience with prostate cancer, an experience that he found in some ways an enlivening one because he said the research was so interesting that he forgot why he was doing it.

(Laughter.)

But when it actually came to choosing what kind of treatment he was going to have, he realized that he had made a decision during a conversation with the surgeon.  He did not realize why he had made the d