THURSDAY, June 24, 2004

Session 4: Aging, Dementia, and Society

CHAIRMAN KASS:  On the record.  Could we get started? With respect to the tour of the Deadly Medicine exhibit, people have asked whether they can go on foot rather than by cab.  It is a short walk providing we know where we’re going.  We are, I think, here at 13th and Pennsylvania, but I don’t know which door out is 13th Street.  Which is—  Laura, you’ll find us to the 14th Street exit.  We’ll walk together.  It’s a short walk.  Others will come by cab if they like, but if we leave here at 4:15 p.m. we’ll be there well in advance of 5:00 p.m. and we can get some fresh air if it’s not raining.

Also before we start, I want to ask.  Professor Binstock and I were chatting briefly at the break about the questions of policy affecting these matters.  That question came up in the last session and he had something very interesting that I think he would like to share with the group.

DR. BINSTOCK:  Last week, I was at a meeting of National Academy of Science that was mostly attended by health economists in which they were looking at the notion of establishing national health accounts.  Up to now, all they’ve been doing is national health expenditures, from what source and how many services and so on.  But now they are looking at the idea of health status and what are the inputs.  What’s particularly interesting is that they have a broad notion of inputs which I think are very relevant to the Alzheimer’s situation which we’ve been discussing.  So, for example, one of the economists unusually declared that informal, unpaid caregiving should be an input into national health accounts even though it’s not a traditional medical service and it’s not being paid for in cold cash, only in sweat and tears and so on.

And then on the other hand, I began to say "Wow", and for the health status of caregivers, you could have a lot of inputs such as respite programs, adult daycare programs, caregivers support programs, all of which the Federal Government is supporting in one way or another, well, not respite programs.  But in any event, now what that means is that down the line some of these things may very well shape up as policy foci for potential support if this development gets off the ground and it would certainly hasten that sort of a thing.  So I just thought I’d let you know that there is something out there.  If anybody is interested in following up from the staff, it’s the DBASSE committee, D-B-A-S-S-E.  I used to know there was a CBASSE committee there.  I don’t know what the D stands for.  They have now graduated, but it’s Behavioral and Social Sciences and Education.  I don’t know what the D stands for.

CHAIRMAN KASS:  Thank you very much.  This little session at the end of the day is meant to be a preliminary taking stock of what we’ve heard and where we might go next in this area.  There have been a couple of topics suggested to us by our guests of things worthy of our attention including questions left by Professor Binstock himself at the end about old age based healthcare rationing, questions about aggressive medical treatment in patients who have Alzheimer’s Disease.

Dr. Hall raised with us the question at the very end of her remarks about exploring the category of partial autonomy, something in between this binary condition of you think you are  autonomous and you’re not and that seems to get in the way of all kinds of important decisions.  There are questions having to do with issues of health coverage for certain sorts of matters.  There are questions about the limitations of the Health Information Patient Privacy Act that is an obstacle to things like getting the caregivers the information that they actually need to give proper care.  These are particular topics on which we could either invite further comment or do some writing.

There were also some of the questions raised implicitly about truth telling or the question Michael Sandel raised earlier about the moral status of this diminished – Put it the way you want to put it.

PROF. SANDEL:  I wouldn’t use the phrase ‘moral status.’

CHAIRMAN KASS:  I know.  Yes, if you hadn’t correct me, he would have.  In any case, we have questions that we can fish out of the transcript.  As far as the Staff has thought about this in advance, since from the quality of the people you realize that there have been people out there thinking about these topics for a long time that it’s not for this Committee to reinvent the wheel or to do a lot of staff writing here.  But one of the things that has occurred to us is that we could on the basis of these discussions and your input lift up to view some of the best things that have been thought and that are being thought in the form of a series of commissioned papers once we identify the topics and identify the people for which we, Staff and Counsel could write suitable introductions, suitable conclusions and make as a matter of much more visible public attention some of the best thinking both about the science, the clinical care, the life cycle questions and some of the ethical issues that this group at least could identify and invite other people to comment on.

But that’s one possible thing that’s occurred to us.  I know that there are people in the room who have spoken and who have other things to say, but we are free to develop this topic as we would like.  It’s clearly an important topic.  The question is whether we can do this in a way that would be of some use and some help to the public.  I just open for general comments or specific suggestions.  Ben.

DR. CARSON:  Well, in the first sessions in the morning, we talked a little bit about aging and perhaps the shifting definitions of who is old, etc.  Obviously when we look at this compared to the last turn of the century before this prior one, we were looking at an average age of death in this country of 47.  We’re close to doubling that now.  At the rate we’re going, we will probably add substantially to the average life span.  At some point, I think it might be a wise thing to discuss the question of because we can prolong life to 200 should we do it and what are the implications for society for doing such things.

CHAIRMAN KASS:  Frank Fukuyama.

PROF. FUKUYAMA:  Well, I have a purely ethical rather than public policy issue that I think we should discuss which is what are the obligations of the caregivers to the elderly under the current technological circumstances because it seems to me everybody by nature grows up understanding that they have obligations to take care of dependent people at the beginning of life when they have children and at the end of life when their parents get old.  A lot of the pictures that were displayed by Dr. Cole suggest that understanding of the cycle.  But it seems to me that modern biomedical technology has greatly intervened to distort that cycle in a lot of ways.

It just seems to me from listening to the discussion of what Alzheimer’s is that in a way it’s a clear byproduct of all of the other cumulative advances in biomedicine an unintended consequence.  As I understand it from the presentation from Dr. Selkoe, you have this polymorphism in this item that’s not a gene, but it’s a protein that has obviously, well, it’s produced by a gene, a very positive impact in early stages of life, but in later stages of life, it leads to the build-up of these amyloids.

You can see how in evolutionary terms the former characteristic was selected for, but most people in hunter-gathering societies didn’t live to the age where the negative effects could take place and so there was never any evolutionary pressure to select against that particular characteristic.  Now we’ve managed to alter the situation such that you have this extremely unnatural disease.

Now the question is I think everybody feels a little bit guilty that we now ship our parents off to nursing homes rather than doing what we would all like to do which is to care for them at home.  The question of obligation is a really complicated one because do you have the same degree of obligation when you are facing basically a terrible disease that no one has ever really had to face in human history before where you have a ten year period of this very gradual, very high level of dependence that requires especially in the later years a much higher level of commitment.

Now previously when all of this was done in families, it was also dependent on certain social structures that no longer exist.  Either you had very large kinship systems in which you could have collective responsibility for the elderly.  Quite frankly, in traditional American society and this continues to this day, a disproportionate obligation for caregiving is on women and particularly if there’s a family and there are siblings, it’s always the daughter that ends up spending much more of her time doing this sort of thing.  In a traditional society, that worked because the women were not in the workforce and basically they made the transition from taking care of their children to taking care of either their parents or their husband’s parents.

Obviously that doesn’t work in present circumstances and so what are the moral obligations for people’  How guilty should we feel for asking either that professionals take over this responsibility privately-funded or to what extent is there actually a public obligation to relief families because in fact this is a good case, since it clearly has a genetic cause and it’s not equally distributed among the population, for the socialization of the costs and risks of this disease which is a good case, I think, for a public intervention to equalize outcomes.

CHAIRMAN KASS:  Thank you.  Peter.

DR. LAWLER:  Just to add to what Frank said, it seems to me the big issue lurking all day is the status of voluntary caregiving in a highly individualistic, high tech society.  What Professor Binstock said this morning in effect is our health system would collapse.  We would all go broke if most of the caregiving wasn’t done by the family and in fact, most of the caregiving wasn’t done by women.

The burden is greater.  Alzheimer’s just being one example.  The resources are going to be less in certain respects with women working, with fewer children, more elderly people.  More people unless the cure is discovered are going to have Alzheimer’s and other debilitating diseases that aren’t as bad as Alzheimer’s but plenty bad.

So it’s not just an ethical issue, but it’s a question of what sort of support government should give to voluntary caregiving especially since there’s not only a necessity, but there are all kinds of rewards as Paul talked about that is a large part of being human and seeing the truth about things.  Children should see people die even long agonizing deaths.  It’s not as bad as clinical evidence would suggest.  So I share the nostalgia.  I’m not old enough to have it, but I share the nostalgic thought  then.

So is it good for our economy, indispensable for our economy and maybe indispensable  for our souls to encourage not just in the abstract ethical way, but it should be public policy encouraging voluntary caregiving because from the  point of view of justice, this may point to socialization.  But there is really a great loss there, so maybe we ought to sacrifice a little justice in the name of love.

CHAIRMAN KASS:  Michael and then Gil.

PROF. SANDEL:  There’s a lot that we’ve learn and that we can learn from the kinds of presentations that we’ve heard and much of it also that’s very moving in a human way and there’s a lot we could discuss about various public policies to do with the healthcare system and questions of resources which, for the most part, this group has not taken up under the heading of bioethics though it certainly could fall under that heading.

I’m not sure that we have a question here really that we can contribute that we’re well equipped to contribute to.  So I hope that we can have as an open question here in this discussion and later whether this really is something where we can make a contribution.

I haven’t been able to wrap my arms around any focused ethical question that we could argue through and really make a contribution on.  Important though it is, informative though these issues are and moving though it is, I don’t think we want to be in a position of issuing merely hortatory kinds of reports.  We could delve into the resource questions which are hugely important and vexing, but unless that’s what we want to do, a focused ethical question on this topic so far I don’t think has presented itself of the kind that we’re equipped to contribute to.

CHAIRMAN KASS:  Someone want to join Michael or Gil.

PROF. MEILAENDER:  Well, I want to propose a focused ethical question.  Does that constitute joining?

CHAIRMAN KASS:   I suppose that’s an answer.

PROF. MEILAENDER:  I mean I’ve been thinking about this for a while because I think in what we’ve done up until this meeting and even more so, what we’ve done in this meeting, what we have is an enormous amount of really rich fascinating material, but also a sense that you’re kind of going round and round and not quite sure where it might go.  I think there is a direction that we could take a little piece of it and actually give it some focus and say something that I myself believe would be useful to say.

Here’s the way I would put it.  I would start from the issue of advanced directives that we looked a little bit at and if you actually look at the history of it, the history of the development of advanced directives a quarter century ago was mainly to move from a perceived medical paternalism to a more autonomy based system where a person’s own decisions could take effect.  What I think we could really usefully do is question that movement and question whether a return to a certain kind of understanding of best interests specifically now with respect to aging, demented patients wouldn’t in fact be an important thing to do.

So that we could begin with the history.  We could look at the mounting evidence that the turn to advanced directives has failed in fact.  I think there’s an awful lot of really powerful evidence that it hasn’t in fact worked.  We could take up some of the philosophical problems about identity and continuing one’s identity in the future that we talked about last time without turning it into a philosophical paper and then we could think about what it would mean particularly with respect to this group of patients to think more seriously about not just extending their autonomy into a period where they don’t have it anymore, but thinking in terms of their best interest about participation by a whole range of people, the caregivers, the patient while the patient has partial autonomy, taking up that partial autonomy issue that came up, some of the issues about who had to have information that the HIPAA discussion raised and  we could actually say something that in a certain way redirected policy to a degree, redirected it by paying attention to some very practical issues to some larger philosophical questions and focused it on the particular class of patients, namely the demented aging patients that we’ve been talking about.

Now that would leave to the side a great deal of other really rich stuff that has crossed our path along the way.  It might be that the kind of collection of essays that Leon was talking about done in conjunction could as it were pick up some of that rich stuff, but it would also give us a more focused project that seems to me to be within the scope of our capabilities to do that relates to some of the things we’ve talked about.  So something like that is at least one idea for how one might pull some of this stuff together and give it a focus.

CHAIRMAN KASS:  Comment to Gil’s suggestion or other suggestions?  Dan, did you want to speak to Gil’s idea?

DR. FOSTER:  No, I’ll wait.

CHAIRMAN KASS:  Mary Ann, then Dan.

PROFESSOR GLENDON:  Well this is in response to Michael’s question and further to what Gil said.  It seems to me that there is a value in making more visible much of what has surfaced here today, not necessarily trying to answer the questions or even make policy recommendations.  But suppose we ask the question ‘What is likely to happen in the not-to-distant future knowing all that we learned today if things just continue the way they are continuing?’  Is it fair to say, the experts here could give us an opinion on this, that there is a crisis looming because of the confluence of a number of circumstances, the continually expanding population of dependent elderly persons, many of whom have Alzheimer’s but there are other kinds of frail elderly  with greater longevity.  Where are the caretakers to come from?

Paul evoked a time that some of us can remember when caretaking took place in the home.  That was a time when young adult women were at home.  That population of caretakers has disappeared.  Right now, what we have with Alzheimer’s very often is a elderly person taking care of another elderly person.  So if you look at these developments, the movement of women into the paid labor force, then the expanding population of the frail elderly, the fact that there is certain stigma as Bill so eloquently wrote in his essay long ago attached to the condition of being dependent, that stigma also attaches or at least a lack of recognition and reward attaches to people who care for dependents and become dependent themselves in the process of caring for dependents, I think it’s a useful service and one with ethical dimensions if we lift that up, make it visible and maybe suggest that attention needs to paid to recognizing, rewarding and compensating caregiving.

CHAIRMAN KASS:  Dan.

DR. FOSTER:  I don’t think I have anything very profound to say, but what I’m worried about is something you’ve really hinted at.  I mean these issues that we’ve heard this morning by the very presence of experts and large numbers of people who have addressed both economically and in some sense make me worried about what the council would have to say about that.

I’m sure because the Staff writes very well and then we spend weeks and so forth editing these reports, the reports have been usually pretty widely praised for their content, but it would be hard for me to get really excited about simply reviewing the evidence about the aging and about Alzheimer’s and so forth.  I mean to write a philosophical report about this which the literature is already filled with might bring it up to the business, but I’m not sure that that’s what we are designed to do.

We started off with cloning— Most of the things that we’ve done have been sort of certainly pressing problems.  We started off by cloning.  We’ve talked about stem cells.  Even the ‘Beyond Therapy’ document had to do with questions that are serious questions for the future that had not really been addressed in the same way that anybody had done.  I mean we talked about some of them.  Ben wasn’t there at the time, but at the time we did talk about making people live a long time.

So the question is in ‘Beyond Therapy’ — I mean ‘What it Means to be Human’ background material was widely received.  So we can write good papers that a few people will read and think that they are — And we’ll probably get it in The New York Times either pro or con or something like that.

But I just don’t see anything at least so far to me that grabs me to say this important that a national council — Remember we were told at the start that a council is the highest advisory body to the Federal Government.  It’s not a commission.  I mean it’s not a committee to do it.  It should address things of high interest and there was a national interest and there’s a continuing national interest about the issues that we started off with.  That is the two goods that we talked about, a calling for research and so forth.

Even our last document was of an important issue which we were unanimous on because it at least gave some guidelines to maybe breaking the deadlock in the Congress about what to do about more cell lines and so forth.  You remember that we’d ignored the whole issue of cloning for research at that point.

In one sense, I mean colleagues would say — I’ve had several people ask me and I’ve mentioned this.  Leon, I said I wasn’t going to say anything about this, but not for any decisions here, but a lot of people say ‘Well given the things that have happened in the country, the Reagan death, the Sapphire article about Reagan’s legacy, about additional lines and things of that sort, when is the council going to look at these issues again?  Everybody else in the country is talking about it and there is an absolute silence from the Council on Bioethics about it.  That may be valid.

We’ve made our decision as to what we do, but things do change.  You have 51 Senators who are saying we ought to get more lines and so forth.  I’m not addressing it all, somatic nuclear transfer.  I don’t think — So I just don’t find myself excited about the sort of things that have been suggested here when we have such a vast amount of material.  If you want to do what Janet raised about the distribution of resources for medical care relative to the aging or to the non-aging, that might be something to do.  But I would hope that we would come to a question that would make you want to come to Washington to spend a day and a half and address your time on that is at a level of ethical content that might be considered major rather than an ethical question which many people might think was minor and I think we ought to address the — I would hope that if we’re going to do something in this, we ought to —

Now there are a lot of other things that we could talk about that I think might be more major  but I’m not going to go into those things.  That’s my concern.  I’m not really excited about anything I’ve heard so far that would be at the level that I would think that a national council should address itself to.  I think that National Academy of Sciences or the Institute of Medicine could address these issues because they’re not in some fundamental sense major ethical problems I think, but maybe I’m wrong on that.

CHAIRMAN KASS:  Charles, Rebecca and we’ll stop.

DR. KRAUTHAMMER:  I was saying to Mike Gazzaniga during the break that what was refreshing about today is we’ve gone a whole day without talking about embryos, but I spoke too soon.

DR. FOSTER:  Forgive me, Charles.

DR. KRAUTHAMMER:  Well, you set me up for that one.  I would stay away from discussing the economics.  It is the huge issue.  It is the looming issue, but it’s a political issue and I think that the people on the Hill are much more equipped and they have politics as the authorization allocation of the resource.  I think I would leave that to the politicians.  It is an important issue.  I’m just not sure it’s ours.

I had exactly the same line of thought as Gil.  What intrigued me and I don’t know that it rises to the level of national crisis.  It doesn’t, but the most interesting issue I think is the issue of autonomy.  It is related exactly as Gil had said to the earlier discussion we had on advanced directives.  It seems to me in Alzheimer’s you have a gradual loss of autonomy and in advanced directives we’re often talking about a sudden accidental, catastrophic loss of autonomy and what do you do?

I think it’s an interesting issue.  I don’t know that it’s been dealt with at this level and I think we might contribute something.  I was interested that our last speaker who’s been involved with Alzheimer’s for 20 years make a plea at the end for us to look at this issue of the binary on-off, yes-no, autonomy status that we now have legally.  I think that if we thought about this, it’s a much broader issue.  I think it would open up other areas.  But I think it would be interesting. It would be focused and it would not be cosmic, but it would be worth our while to do.

DR. FOSTER:  Can I just respond to that?  We’ve been using the public language of autonomy and doing no harm and justice and benevolence for a very long time.  It’s the public language of bioethics.  The thing with autonomy began with the National Commission.  It seems to me that autonomy may be this is so different from other aspects of autonomy but whenever autonomy is impaired we have a responsibility to meet it.  I don’t see why you’re excited about doing something about that.

To tell you the truth, I’m actually — I’ve read so many papers on autonomy that I think that where we are now that it’s sort of boring.  All we’ve done, let’s say, is change from taking care of somebody with Down’s Syndrome or something to somebody who is at the end where they have multi-infarct dementia or Alzheimer’s dementia.  What is the difference between an impaired autonomy at one stage or another or one disease or another disease to do it?  I mean why would that be exciting?

DR. KRAUTHAMMER:  I don’t think it has to be Alzheimer’s specific.  I mean when you talk about advanced directives it’s not Alzheimer’s specific.  I think what we did hear in the discussion of advanced directives is that the system that we thought was a solution in the hay-day of autonomy 30 years ago and everybody assumed in all aspects of life, marriage and divorce and sexuality, that autonomy is the answer, we’ve been rethinking autonomy in a lot of areas of life and seeing its unintended consequences.  This would be an interesting area to look at it again.

Again I’m not making a claim that it’s going to revolutionize our thinking, but I think it has practical implications.  People are telling us the system that we had devised is not really working.  We might have something to offer as a practical alternative.

CHAIRMAN KASS:  Rebecca.

PROF. DRESSER:  See I have exactly the opposite view from Dan as far as what’s important for a Bioethics council to take up and I think this is a problem with the field.  We get caught up in these sexy topics like cloning and stem cell research and I think they are very important because they are new issues and somebody needs to think them through, but there are all these everyday ethics issues that really affect people so much and we have a lot of writing on autonomy, but a lot of it is not very good.

I guess I would maybe think about a project that’s a little bit bigger than what Gil said under a rubric of something like what is aging and death with dignity in the 21st century, develop countries.  I don’t know if we want to take on developing as well, but I think that’s a huge ethical challenge.  I don’t know about you all, but I was sitting here all day thinking about myself, my family.  It’s something that most people are going to cope with.  I, as a member of the Narcissistic Baby Boom Generation, think we’re all going to think it’s extremely important and people are really going to be grappling with this.

There isn’t a lot of buy-in to the traditional spiritual institutions that guide us through these things and I think this will be a social crisis as well as a kind of an existential crisis over the next 15, 20 years how to deal with these things.  So I would really hope that we could take this up.

PROF. SANDEL:  Could I ask Rebecca.  What is the ‘this’? You raised actually a more interesting topic to my mind than autonomy.  Death.  Death is an interesting topic.  Autonomy by now has been so chewed over.  Autonomy is dull.  Death is interesting.  So when you say, ‘Yes, I agree we should do this.’  What’s the ‘this’?  You started out saying I agree, but then you gave a very different thing.  So what’s the ‘this’ exactly?

PROF. DRESSER:  This is death with dignity, if we want to call it that.  Thinking about it from a broader perspective acknowledging that autonomy is not going to give us the answers and how we do approach it with a better way of thinking.  I’m not sure what it is, but I would love to hear what people like you think about it.  So I guess I would say in terms of thinking about our futures as aging people, as people who will need a lot of healthcare, as people who will have relatives who need a lot of healthcare, how do we approach this journey? What’s, I don’t want to say a health way of thinking about it, a rich, moral way of thinking about it?

DR. FOSTER:  Well, let me just say, so you want us to go back to ancient questions of what does it mean to die that everybody from the prophets of Israel to every seminary to everybody else has addressed over and over.  So we’re going to come together as a council and we’re going to say how you die.  What is your hope for death and whatever?  That’s going to become a subject.  I mean I don’t follow you.  I really don’t follow you as to what you think we were going to do here.  Now I’m pressing pretty hard, but I think like Michael.  You’d better be specific.  Are we going to say ‘Well, what do the polytheists think about death?  What are we going to do?  I mean what do you mean by death by dignity.  I just want to push you to that.

CHAIRMAN KASS:  Gil, do you want a tiny comment while Rebecca thinks about that?

PROF. MEILAENDER:  Yes, just a sentence.  I just want to reemphasize that my notion was not that we should take up the concept of autonomy.  My notion was that we should say that what has become our public language turns out to be bad public language and we should think about different public language.  That seems to me to be a rather useful interesting thing to do.

DR. KRAUTHAMMER:  I think autonomy is one way to answer the question and the question is who decides.  As people lose their capacity to make decisions, who decides and how do you establish structures that do that with regularity and with justice?  I think that’s an interesting question.  There are a lot of people who— And it comes up in several contexts.  Autonomy is one of the ways of approaching it.  I think Gil tends to be skeptical about it.  I may be more of a libertarian but those are different answers, but the question I think is interesting and I don’t think it has a very good practical answer today and we might look at it.

CHAIRMAN KASS:  Well, we’re going to have to stop.  Let me say one sentence or two.  I share the view that the Council’s work together has to be on something sufficiently focused, sufficiently clear and sufficiently deserving of your energies and time to bring you together here to make it worthwhile.  There is no argument about that.

The last time we started on more specific topics, at least the question of advanced directives was on a particular topic whether this is indeed the way to enable people contemplating their future to this is the best way to set up the care for the people who are aging and dying to allow them to somehow govern this with a piece of paper written 20, 30 years in advance.  Jim Wilson who couldn’t be here actually set himself the task of reading all of the literature on advanced directives and he said he thought it was largely bankrupt.  He really didn’t think that that was somehow going to be adequate to the task that we had.  Durable power of attorney was somehow better but that he was really at work on this topic.  And I do think that we will work to try to organize and focus some kind of question that is a question that is researchable and is manageable for us.  If we can’t, we won’t do this.

Having said that, I do want to put in one kind of a plea for the larger view of this, not that we were going to have a staff written report of the sort that we had before.  But I fear that as this conversation proceeds with an aging population and with a increasingly demented population that this will be handled in one or another of the usual bureaucratic ways.  That there will either be simply a economic and demographic approach to this matter or there will be simply another kind of biologized view of what you have to do to somehow move in there and alleviate these symptoms.

Whereas I think Tom Cole gave us in a way what he took to be the most important question of this particular age where there is no longer a circle and there’s no longer even a view of a sequential and graded scale of what actually does it mean to be old and to be infirm.  Now that’s not a question of burning public policy, but if we were to pull commission papers, commission papers drawing on things that people know, there is at least a way that a richer bioethical approach to those questions could be  put between two covers so that insofar as that conversation proceeds using the things that the experts already know, we might have not only lifted the matters to view, but given it a certain kind of richer, deeper and more humanistic shape so that it simply doesn’t become yet one more problem for managers or deniers of one sort or another.

Now that would not be writing a report that’s already been done.  It would be a matter, if we go forward with such a thing, of thinking through what are the specific large questions of present policy or present thought that deserve a voice in this discussion.  But that would be not a substitute for finding a focused question for us to tackle here.  I do think that it’s incumbent upon the Staff and myself with your help to try to formulate such a question or else go somewhere else.

The reason we had the conversation we had today was to give us a kind of larger background for seeing where the particular pieces might fit.  We started rather small last time.  We’ve now painted a larger picture and I think we take for ourselves the task.  Bill will be one of our major consultants and in trying to think this through we will consult with you over the weeks ahead and try to formulate something.

We go now to the museum.  Someone will show us the 14th Street exit for those of us who would like to walk.  Dinner is at 7:00 p.m. at 1201 Pennsylvania Avenue for those who are not going to the museum.  We will be here if people would like to leave their things at their places.  And tomorrow morning for those of you not joining us, we start at 8:30 a.m.  Off the record.

(Whereupon, at 4:31 p.m., the meeting of the Council on Bioethics was concluded.)