THURSDAY, September 8, 2005

Session 1: Ethical Caregiving in Our Aging Society I: Larger Issues

Council Discussion

 

CHAIRMAN KASS:  Good morning.  Welcome Council members, welcome members of the public to this, the 21^st meeting of the President's Council on Bioethics, the last meeting of our second term, which concludes September 30^th of this month.  Recognize the presence of Dick Roblin, the Designated Federal Officer, in whose presence this is a legal meeting.

A couple of matters of personnel.  Since we last met there's been one change in the membership.  Our colleague, Jim Wilson, resigned earlier this year, having served long and well.  I relied on him for his sage advice, his great good sense, especially in the tough times.  I appreciated very much his skepticism about mere speculation, and the attempt to turn speculations into prediction without doing proper research.  I think I speak not only for myself but for all of us in expressing our gratitude for his excellent service and for his wonderful collegiality.

Second, I want to put on the record my own personal gratitude to my friend of longstanding, Dick Roblin, who was our scientific director until he retired last January to be Senior Consultant for scientific matters, but when Yuval was summoned to work in the White House on the Domestic Policy Council, Dick kindly agreed to come forward and serve as the acting Executive Director to steer us through to the end of this term, and my deep gratitude to you, Dick.

The plan for this meeting is simple.  Today we will try to finish old business, and tomorrow we will look forward to the future on the Council's third term.  Our old business is the conclusion of our work on "Ethical Caregiving in Our Aging Society," with special attention to questions of caregiving for persons with dementia.

This is a process in which we've been engaged really since April of 2004.  I was surprised in reviewing things for this meeting, we actually had 17 prior sessions on this topic over the last year and a half.  I won't review all of them, but we've had guest presentations and numerous discussions amongst ourselves on the whole range of topics, and eventually settled on some we thought could be rendered manageable, and about which comments from us might, in fact, be useful.  And since our last meeting, a report has taken shape with heavy lifting by Eric Cohen, who's been spearheading this in the office with assistance from others, notably Adam Schulman in the drafting.  And from Council members, especially Gil, Rebecca, Paul, Dan, and Mary Ann.  You've seen drafts of earlier chapters.  We've had comments.  We are moving towards the final stages of this work, and I'm happy to announce that we scheduled a date for the release of the report on the 29^th of September.  And there will be a meeting of the National Press Club in the morning, and a teleconference in the afternoon, where the press that cannot be here will be able to speak with myself and other members of the Council.  And I'll be in touch with you, hoping I can elicit some volunteers to participate in these events.

The plan and purpose for today's meeting is for the Council to, in part, take stock of what we've done and to think about certain kinds of larger residual questions that might occupy us, or someone else going forward.  And at the end of the day, to review the provisional conclusions of our work together.  In between — in order, in fact, to enrich that last discussion — we will have presentations from four invited guests, two from the perspective of caregiving, two from the perspective of public policy, people who have seen an earlier draft of the report, and who will be asked to comment on how what we have done relates to their own activities or the activities about which they are especially interested in, and to offer some suggestions for possible research, and improvement and reform in practices, both in caregiving and in terms of public policy.

In this session, I wanted to flag, at least a few questions that are at least still puzzling to me, and are questions that have come up but that we've not, I think, properly addressed both philosophical and practical individual, and cultural.  And then to highlight one or two of them that I think might pay us to have some discussion about.  And this comes, in part, out of comments from some of you in earlier drafts.

The first two are things that we've had a fair amount of discussion about.  The report has in a way taken a position on these things, so I don't think we should be discussing them at this point, but I don't think we've heard the last word on these matters. 

The first is the general question about how to think about dementia in relation to the human person and the life cycle.  It was, in fact, the subject of our very first meeting in response to a paper by Gil on the subject of dementia and identity.  Is this really one way of being old, or is this affliction, which is though age-dependent, better seen as a disease or an assault on the human person? 

And related to that, the question is, is this a very special kind of disability, especially devastating to human possibility, or is this, however much we might be inclined to think that, rather a paradigmatic case and the foreshadowing of loss of human control all together?  And the report basically has a take on that, but it makes that question still open in some ways for further reflection.  And I think it should be something that we want to continue to ponder.

Second, the report affirms the longstanding distinction in discussing what kinds of treatments are to be regarded as optional, rather than obligatory, makes much of the distinction between the burdens imposed by added treatment and the burdens of the life being cared for.  And that we have affirmed the ethical importance of this distinction for decisions about the uses of life-sustaining technologies.  So it remains somewhat puzzling, at least to some of us, if the burdens that are now accrued to life are in some measure owed to the choices made in previous treatment decisions, like the man who rescues someone from the river who has jumped in to take their lives.  You pull a man out of the river and you somehow have a kind of responsibility for his life thereafter.  And in one of the topics that I do want us to discuss, I think the question of what happens when technology continues to provide new and additional means that are not themselves burdensome, that are not especially risky, that are efficacious.  Can we continue to uphold this distinction which we have at least for the time being rightly upheld.

The two questions that we've touched on; one we've given almost no attention to.  I know it's of great concern, but not to Frank alone, is the resource allocation question.  Mary Ann taking the lead, Janet speaking forcefully on this subject, and quite concerned about the potential inter-generational conflict that proper attention to the care of the elderly might create.  And we talk about the need to set priorities and to balance our obligations, but we haven't taken up the ethical task of doing that.

There is, of course, a political way to settle this question, and it's not clear that ethical reflection is going to be very efficacious in this matter, but it seems to me an ethics council ought to be willing to try.  And a question we've raised from time to time is what do the old owe the young, not just individually but collectively, and how thinking about this in terms of the common good would one speak about what it is that we owe future generations, and more narrowly, are there any limits that could properly be set on expenditures, and care for those at the end of life, either on the basis of age, or on the basis of massiveness of intervention or the like, or is doing that implicitly to declare certain kinds of lives second-class.  It's a tough question.  I'm not sure that work on it will be useful to policymakers, but it does seem to me, if we're going to speak about the conflict amongst the generations, some attempt to articulate the common good along those lines I think would be very welcome.

One topic which is closer to what we've done, and yet we haven't, I think, faced up to this fully: we focused in our ethical analysis largely on decisions to accept or forego life-sustaining treatments for frail patients, especially those with dementia, when they get sick with other problems.  And we have emphasized in this discussion, I think absolutely rightly, the ethical goal to benefit the life that the patient still has, but I think we've all recognized that this is a rather narrow focus of the subject of long-term care for the frail, elderly, and people with dementia.  Those questions are driven by the advent of disease and decisions made in extremis, but they don't touch those questions that we're going to hear something about later today.  They don't touch the questions about taking away driving privileges, putting people in institutions, all of those every day kinds of questions, which are perhaps not the subject for a Council such as this, but certainly at the heart of the obligations and dilemmas of care givers.  And, moreover, that focus on the end of life decisions, while it rightly focuses on the goals of caregiving at the end of life, doesn't really discuss the question about what are the reasonable goals for the end of life all together?  What is a good old age, what is a good death in modern times?  Thomas Cole raised this question for us.  We've had a little discussion on it, but not very much.  And it's not clear to me to what extent this particular question is proper concern that ought to enter into the ethics of caregiving.

Dan and Paul, when they take care of patients who come to them sick don't sort of sit back and try to ask themselves well, what's a good old age, or what's a good death?  They deal with the suffering and the problems that present themselves, but culturally speaking, these questions do inform.  They inform our practice of medicine, and our practice of medicine helps shape the cultural views of what should happen here.

Now with this, I'm going to come to the end and open this for discussion.  It's the special role of the advances in technology that I think deserve more attention than we've paid to it.  Peter and others in their comments have written about this.  We talk about the best available care as an obligation, regardless of disability.  But best available care here and now is not a static matter, and because of the progressive character of medical technology, this standard best care for the person as she or he is now, is always going to be in flux. 

Saving interventions that are today optional at best because they're either burdensome or risky will, as technology advances, likely become increasing safe and routine, so there seems to be a ratcheting effect in what turns out to be not only acceptable, but perhaps even obligatory under the standard of best care. 

Today we say in most of our cases in ethical analysis of best care, we'll say yes to antibiotics in most cases, but no to organ replacement or dialysis.  But what happens if these other things become more proficient in these matters?  Are we really going to be obliged always to say yes to these things, regardless of the condition of life, the people who have it?

If regenerative medicine begins to pay off in  the way in which its prophets are predicting, does that really mean that we're obliged to offer and consider morally obligatory the provision of replacement of organs or replacement tissues if those replacements are not themselves burdensome, and are efficacious?  I know, again, this is not the question that comes up in the clinic, but it is, I think, for people who have taken a stand on the best care standard, have to pay some attention to what the changing technologies do, I think, to our moral thinking about this.  So that's, I think, one question that I would like to pose.  And perhaps we could start with that, and then devote some part of the time to the resource question and the ethics of inter-generational obligation.  Was that too long-winded and not a sufficiently clear question at the end? Do you want that formulated as a question?  We are now more or less collectively agreed that the obligation to seek the best care of the patient, to serve the life the patient now has, is not obligated to introduce treatments that are inefficacious, are excessively burdensome.  Those are optional, and sometimes even should be not foregone.  But what happens when technologies to further and further extend life, and further and further rescue become available, become non-burdensome, if that's the case, and become common?  Can we simply say that we're under a kind of moral imperative to continue, and to continue, and to continue?  Or is there some kind of built-in limit connected with the view of what is a proper end-of-life kind of finitude, or are we constantly on the treadmill or on the escalator going up?  Alfonso.

DR. GÓMEZ-LOBO:  I have no position to solve the problem, but I would like to emphasize some of the problems that you mentioned, particularly the following; that the traditional criteria to distinguish between ordinary and extraordinary means, of course, is the benefit/burden deliberation, but it seems to me that that's precisely what the medical practice tries to achieve.  In other words, more benefit, being more efficacious, and less burdens, less side effects.  You'll correct me if I'm wrong, Dan, but if that's the case, then we're on a collision course here because on the one hand exactly the criteria that are supposed to allow us to figure out when treatment should be stopped are exactly the criteria that are compelling, that are driving forward the medical progress.  So we have a need to step back and re-think the criteria, it seems to me, in ways that are not clear.

Now it's one thing to talk about serving the life of the patient.  Now there there's a possible pitfall, as well, and that's something I think I learned from Gil; namely, that we should not come to the point of thinking that the life itself is the burden because, of course, that puts us into another quandary, so it seems to me that there's a need for conceptual clarification in two areas; one is on re-thinking benefit/burden criteria.  And two, re-thinking the question well, ultimately I didn't want to use this expression but I have to use it, the quality of life issue.  I think that those are exactly the two points where we are facing these problems.

CHAIRMAN KASS:  Gil.

PROFESSOR MEILAENDER:  I'm really going to reply to your question with another one in a way, and I don't know how helpful that is, but I have a hard time thinking about the question in just general terms.  I think about it in the specific instance, but I have a very hard time figuring out kind of what it means in general terms.  Just by hypothesis, if organ replacement became as simple and non-burdensome as getting a shot, your comparison was with antibiotics, it became as simple as that, then why wouldn't you do it?

See, the hypothesis is that technology will make this every bit as helpful and every bit as non-burdensome to the patient as receiving antibiotics.  Okay.  If that were really the case — see, I have some doubts whether that will ever happen — but if that were really the case, then I'm hard-pressed to figure out exactly why one would decline it, except for maybe  some larger questions about it.  I mean, I could see if someone who didn't want organ replacement for other more kind of philosophical reasons.

CHAIRMAN KASS:  See, this ties into one of the larger questions I raised at the beginning, which is to say what is, in a way, the tacit teaching about what it means to have old age, to be part of a life cycle, and what kind of view of a good end of life, as opposed to good end of life care, are we talking about?  And by the way, lest I run afoul of the practitioners who will correct me if I don't correct myself, no one is going to say that organ replacement is going to be like taking a shot.  I mean, this we think would be difficult things, even if you're just squirting in heart muscle cells, which are going to go to... it's going to be much more complicated.  But the general point is that more and more things are going to become easier to do, and relatively less burdensome than they now are.  And if the point is that there's no such thing as enough, because anything which is possible and relatively burden free becomes obligatory, then this particular moral principle, coupled with the technological imperative produces a kind of continual ratcheting up of what it is that we owe, and what it is that is obligatory.  And that seems to be a limitless enterprise, which is very much at odds with notions that you and others around the table have expressed about the shape of the life cycle, the accepting of limits and so on, so I'm wondering whether we can in the long term sustain the kind of moral principle that we have held here. 

I mean, I'm not trying to make it — I can make matters worse by saying, and by the way, what that is that's going to produce 20 years of people with dementia rather than 5 or 10.  I want to treat it without that further complication.  Mary Ann.

PROF. GLENDON: Burdensome not only means burdensome in the physical sense, but also these treatments are likely to be very, very expensive, so I don't see how we can get away from the other question that you raised about allocation of resources.  Our report focuses on one set of problems that are likely to arise in the aging society, but let's not forget that another dimension of the demographic change is a lower birth rate, and children become less and less visible, and their needs become less and less the subject of political attention, so I don't think we can discuss your question without discussing how somehow this debate could be structured so that it won't head toward conflict between the generations, but toward finding ways to expand the pie, to emphasize social solidarity, what the old owe the young, and what the young owe the old.

You're right, politicians may pay no attention to it, but if there's a role for this Council, it certainly is lifting up that dimension of the problem.

CHAIRMAN KASS:  Rebecca.

PROF. DRESSER:  One concern I have is you mentioned the technological imperative, and I think if we can agree that best care does not always mean treatment, and that treatment doesn't have to be given  if it's inefficacious and excessively burdensome.  Then the question becomes well, how do you define that, and there are lots of ways to define that.  And my concern is in our society and medical system, we tend to define it in a more narrow way than I would prefer to define it.  And there's a tendency to think that these emerging technologies ought to be tried on everybody, when one could make a good argument that it really is not efficacious for the patient, and it's excessively burdensome.  Sometimes no one is there to make that case, and so I think one area where we need to work is to enrich this notion of what does it mean to be inefficacious?

I mean, virtually no treatment is 100 percent successful, and so what are the percentages we're talking about in a particular aging population?  What are the success rates, what are the complication rates?  I think in many cases that are good questions about whether using these things are best care for the patient, and that's a way to set some limits on use of these new technologies without getting into age-based rationing, or rationing on the basis of dementia and that sort of approach.

CHAIRMAN KASS:  Dan.

DR. FOSTER:  I want to support a view that Mary Ann has just made about the economic arguments.  This doesn't justify to the aged or — we treat congestive heart failure with about nine drugs today, and you might add there's no question that you live longer if you do this, but the costs are enormous for these drugs, so even in the non-aging or the poor, we have this problem that many physicians are very nervous about.  We have to deal with this every day.  I mean, what percent of improvement do you get from these nine drugs?  It's pretty small.  Same thing for the treatment of cancer.  A big advance from — well, I won't mention any companies.  And what it does, it adds two months to the life of somebody who's got lung cancer and so forth at enormous cost, so I don't see how you can avoid the economic argument.  And it's not immoral to consider the economic argument of the cost.

Look, all we focus on is the United States, the richest nation in the world and so forth.  We make the argument in Africa all the time, we'll give one drug of AIDS, if we can do that at all.  I mean just to give a drug so that a mother doesn't have a kid with AIDS, and we just blithely think that the rest of the world, it's okay for them to have this economic argument and so forth, but it's immoral for us to consider it.  That's just crazy.  There's not enough pie to support everybody in the world, or even in the United States with the optimal treatment for everything, and so I think it's just silly not to look at the fact that most of what we spend for Medicare, for example, is at the end of life.  We spend millions and millions, and billions of dollars to essentially prolong for a short time, or I don't know what a short time is, so I think this is — if you really want to get serious about what to do, we've got to consider the costs of modern medicine.

I mean, if you just take a Levaquin pill for pneumonia, it's $10 a capsule, so you get six pills and that's $60.  Well, I can afford that, or if you're insured I can do that, but many people can't do it, so it's sort of a long-winded answer to say I'm very much concerned about the economic costs of medicine across the board, and that is particularly going to become important in terms of if you're going to try to apply  everything to somebody, let's say whose life is valuable, is not purely vegetative, but does not recognize anybody else and so forth.  I don't see how you can't play those things into the case.

We went through — I think I mentioned this at some council before — medicine did.  When dialysis first became available, the U.K. decided they would not dialyze people, it was too costly.  And as a consequence, about 3,000 or 3,500 patients a year died in the U.K.  Now public pressure made them reverse this, but that was an economic decision.  But I remember a specific case in Dallas where there was a vibrant chair of a big bank in Dallas, and an SMU student at 18, and there was only the resource to dialyze one of those, so you had to make a choice.  Do we do the potential of this 18-year old person, or do we preserve the CEO?  I mean, we don't do that any more, but those kind of issues have to come into play.  And to avoid them in the sense that every life is of equal value, that's a moral principle that's true, but the practical principle of the larger good has to be made by politicians and so forth.  What is the best good you can get out of the thing?  You said it better than I did, but I just want to say that I feel strongly that that has to be taken into consideration.  And I also want to say publicly, I'm sort of embarrassed that the only thing that we think about in the country about the sick, dying, poor, and starving, or even catastrophes, is the United States of America.  And in some sense, I would like to have the President's Council on Bioethics to consider the world.  Are we meeting as the richest and I think finest, I shouldn't say that, but I'm very proud of the country, finest.  I shouldn't say that; that we ought to consider the moral obligations of the world maybe as something that would be — I know you're going to immediately turn to me and say oh do-gooder, you know.

CHAIRMAN KASS:  No one will say that.  I won't  recognize them to say that.  Robby. 

PROF. GEORGE: I want to go back to Leon's question and try to address it head-on.  I can't propose an answer, but to stick with the question in all its difficulty.  Let's imagine that it would be possible fairly easily through the use of easy organ transplantation or other forms of regenerative medicine, to enable people to live to 250, 350.  Is this not what you had in mind, Leon?

CHAIRMAN KASS:  I don't want to turn this into a science fiction question.

PROF. GEORGE: Give me the life span then.  We're talking about 150?

CHAIRMAN KASS:  I wasn't even projecting a particular age.  I was simply saying we've got people now die of organ failure.  One of the promises of regenerative medicine is at least some of those organs that fail can be repaired when they fail.  The way in which you now repair hips, you might be able to repair defective heart muscle, or a kidney.  You might be able to do something about Parkinson's Disease with stem cell research and various other sorts of things.

PROF. GEORGE: We do — I mean, Dr. Carson and others do transplantation now.  Right?

CHAIRMAN KASS:  Right.

PROF. GEORGE: Okay.  So we've got that problem now.  We think we can handle it with the ethical principles that have traditionally been affirmed in medicine for now, so it seems to me what makes your challenge interesting is looking at a situation where we're not simply concerned with heart transplants for 62-year-old people that will enable them to live to 78.  I think the question only becomes interesting if we're talking about forms of regenerative medicine that are going to enable people to live to much older ages, or am I wrong about that?

CHAIRMAN KASS:  Well, let —

DR. FOSTER:  Let me interrupt.  You're not going to make great changes in life expectancies with modification of transplantation or things of that sort.  If you're going to do that, it's going to be manipulation of genes.  As you know, as we've heard here, we know the sirtuins and the genes that are involved in aging.  We know that.  We know the genes are the same in the flies or the slime mold, or in the worms.  You remember that we heard that manipulation of simple genes in the insulin pathway can cause a hermaphroditic worm to live six times the normal pathway, so you could be — if you altered that in humans, I don't that we'd be like the worm, but you could conceivably live to be a Methuselah if you did that, but that's not going to happen with drugs or things of that sort, unless the drugs change the genes, so I just wanted to try to answer that specific question.

I don't think any of the scientists that work on aging and the prevention of aging, think that technical advances like transplant or something like that are going to have a big effect on it, Robby.  I just wanted to interrupt to make that point.

PROF. GEORGE: No, I appreciate that, Dan, and I do remember that being reported to us, but I think that Leon's problem only becomes an interesting problem if we're talking about significant life extension.

CHAIRMAN KASS:  No, let me see if I can help.

PROF. GEORGE: Unless you — then the alternative would be to build-in the problems that I thought you wanted to factor out at least for now in order not to ratchet it up of dementia and other — the extension of life in debilitated circumstances.

CHAIRMAN KASS:  Well, we've talked in here before making use of Osler's remark about pneumonia being the friend of the aged.

PROF. GEORGE: Yes.

CHAIRMAN KASS:  And, in fact, it's in drafts of what we've got here, and there's a question as to whether in that sense the old man has any friends at all, partly thanks, in fact, to the great gifts that have given him a much longer life.  And the question is, is tech — and Dan Callahan, for example, tries to write not by thinking about the lifespan extended to 150 or 200, but think about the decisions now made, and he has — I think Gil will correct me on this — he's got sort of two ways of trying to decide whether something is optional or not, and its use.

One would be to say would you have invented a feeding tube so that you could use it in Terry Schiavo?  If the answer to that is no, it's not obligatory to use it.  And the other one has to do with mourning.  Do you have it?  I don't want you to become a defender of it, but there are two kind of criteria as you try to decide — he's trying to repair to some view of a natural life span, and to say certain kinds of things — we've somehow changed the capacity of us to have a certain shaped life, and it's partly the result of the new choices that technology has produced.

Now if we're already at that kind of stage where those things are questions, and the doctors will tell you those things are questions for them right now, you don't have to imagine a life span to 150 to say what happens when we've got new and additional things which are relatively burden-free physically.  The expense question, I haven't forgotten.  I'm going to bring it back shortly, but bracketing the expense question, how does the teaching benefit the life the patient now has?  Do not somehow set yourself against that life.  How is that going to play out?  Are we're going to have to, in a way, adopt the view that whatever is available and efficacious, and not too burdensome is somehow morally obligatory?   Otherwise you get accused of trying to orchestrate the end of your life, or setting yourself against the life the patient has.  Right now I think the moral categories — this is to underscore Alfonso's point — right now I think the moral categories still work, though people are nervous about it.  And some of the people who are nervous about it run to write living wills because they are afraid they're going to wind up in circumstances that they don't like the life that these benefits will purportedly benefit.  That's, I think, our complication.  Now I don't know if I've helped you or hindered you, but I don't want to put this —

PROF. GEORGE: No, I think you've made me more confused about the question.  If it's essentially the same question we have now in the case of an elderly person whose life can be extended with antibiotics, it's essentially that case, but the number is being increased by an additional 20 or 25 percent because of advances in regenerative medicine, that would be one thing, and it seems to me that it's less of a challenge, at least for people who think that the antibiotics generally ought to be given, which I gather we've as a Council committed ourselves to.  Then it doesn't seem to me to be the kind of big problem that you wanted us to think about.  If you alter it so that we're not talking about a higher percentage of people facing the same challenge that we face with a certain percentage of the people now into the area of life extension, then I think it does become a big problem, in part for reasons that Mary Ann and Dan have already articulated, and not just the economic ones, but also the demographic ones, and that it's going to shift how one leads a life, and our whole understanding of our relationship to our work, to our education, to other generations.

I mean, it's going to have a huge social impact, some of which might reasonably be regarded as so negative as to warrant the judgment that we ought not to make it a project to go into that life extension, to try to accomplish that.  And I think that judgment could be made without violating any of the ethical norms that we've affirmed.  But then that raises, I think, the Callahan problem.

What if it happens anyway, and we do find ourselves in a situation where we face the option of very long lives without great burdens from the means that enable us to extend life in that way.  Could there be a legitimate reason for declining in individual cases the use of those means?  And what I would take to be a legitimate reason in light of the principles lying behind the criteria that we've identified as the ones to be focused on in making life and death decisions, could such decisions be made without the reason for the decisions being the proposition that the life in question was not worth living, a life unworthy of life, and that the person facing the decision, or the surrogate making the decision for the person regards that person as better off dead.  It seems to me there may be.  I have trouble, and here's where I find your question so interesting, I have trouble articulating what that other reason would be in the precise circumstances I've outlined.  But somehow I share your intuition that yes, the decision a person would be making if the person made the decision to decline that care would not necessarily be rooted in his affirmation of the proposition that this life I've got is a Leben unwertes Leben. 

CHAIRMAN KASS:  I think you've captured, in part, the nub of what I'm worried about.  The intuition of  Osler seems to be somehow right, especially if you think there's such a thing as a shape and a terminus.  And the language — we have to find some way to speak about that, I think, without declaring what it is that is offensive and wrong, simply taking the question on your terms.  I think it's a challenge for those of us who have tried to formulate the ethical principles in the way in which we have.  Dan, to this point?

DR. FOSTER:  Yes, to this point.  The practical things, it seems to me — I've tried to argue this in a debate on the volume that's coming out — is that, that the intuitive feeling that you described of Osler said pneumonia is quick and it's a peaceful friend to do that, is a principle I think we ought to hold on to, rather than an absolute continuation of life.

Remember — I don't want to try to get theological here, but remember that the demand to love neighbor as self — let's say in the biblical view.  You remember early in the Hebrew lessons where we were to love God and love neighbor as self, the love for God was absolute, but the love for neighbor was restricted.  It was as self.  You shall love your neighbor as self.  It was not absolute and continuing everything.  It was restricted as self, and I believe that most of us, and certainly those of us who take care of the dying, internists like myself and so forth, or somebody is dealing with dementia, like Paul, intuitively know that they themselves would not like a lot of the things that we do for themselves.  And so one of the things that we need to ask is, if I'm the one lying there vegetatively, and my family is there, would I want them to apply all these things, give me a new organ or anything?  The answer to that is of course not.  Of course not, and so I think that  intuitive sense about this — I mean, I think you've criticized me once about this thing helpfully that we needed even if you're a good-hearted physician, let's say you need moral guidance about what to do, and I think that principle is right, and I'm glad that we're giving moral guidance and so forth, but the intuitive sense about this, the common sense about this seems sometimes to get lost with some devotion to a principle that life always, either in the earliest of phases or in the latest of phases is the highest demand that is made on the moral human, and I believe that's wrong.

CHAIRMAN KASS:  You'll have some takers on this.  Peter was in the queue from before.  I'm not sure people around the table are going to disagree with the last formulation.

PROF. GEORGE: No, what we're going to disagree with is whether that is an accurate account of the position that Dan is, in fact, I think going to criticize since nobody actually, or at least nobody I know actually affirms the vitalism that Dan has there characterized.  Dan obviously has somebody in mind, or some people in mind, who actually advocate a view.  I think we would want to articulate the view we actually hold, and then Dan can take a crack at it.  But what Dan has there criticized is a view I certainly don't hold, and I think others who've defended the positions that I've defended here don't hold it.

DR. FOSTER:  Robby, let me say, I had nobody in mind.  I certainly did not have Robby George in mind, or anything else.  But it can be — sometimes it can be read that way, and all I'm arguing for is a very simple principle; that all of us want to be common sense against the general medical rules that we don't want to have some standard that is unrealistic.  That's all I'm saying.  It was not aimed at anything, and I was just teasing him about telling me that I needed moral guidance.  I need, terribly, moral guidance.

CHAIRMAN KASS:  Peter.  You've been very patient.

PROF. LAWLER:   Robby and Gil, I think, radicalized the question.  Regenerative medicine is highly speculative, especially if it's considered in the full sense of both the rejuvenation of organs and genetic manipulation, so Paul said in his comments on  the report that our lives, the average human life never gets much beyond 80, and when the report speculated otherwise, Paul wrote "No way, Jose."  But that seems to be what distinguishes physicians from scientists, because scientists do hold open the possibility through genetic manipulation, organ rejuvenation that the average human life might get a lot longer, so let's assume, number one, these treatments are not burdensome.  Let's assume, number two, these treatments are not expensive, and we can easily afford it.  Not at first, these problems will exist at first, but as science develops these problems will become less important.  Let's assume that this will absolutely break the life cycle.  Right now our report says thoughts about breaking the life cycle are an exaggeration, but let's say people can live well into three digits.  Safe, reliable, inexpensive treatment. I don't think — what would be the objection to giving it, even if it messed up our lives, or put us into a whole new dimension of human living, which is more or less childless, and requires a wholly new kind of virtue.  I mean, if we can't articulate why we shouldn't do this, why shouldn't we do it?

CHAIRMAN KASS:  Frank, are you going to take this up?  You'll respond to Peter? 

DR. McHUGH:  Right now?

CHAIRMAN KASS:  Not if you don't want to.  I mean, Peter has raised a question, and someone might want to simply have a bit of a response on this formulation of the question.  Go ahead.

DR. FUKUYAMA:  Yes.  Okay.  Well, I do think that it is possible to articulate what a good death is that will help answer this question; which is that a good death is probably one in which you want a few months warning for the preparation, psychological preparation for the family, and then when the end finally comes, all of the systems ought to shut down pretty much simultaneously within a relatively short period.  All right?  And it seems to me the real problem that we've got now is that medicine, whether it's regenerative or organ transplants, or just curing pneumonia is that it keeps some of those systems going, and others it has no effect on, and the whole crisis over Alzheimer's is that we figured out how to keep the body going, but we don't have a similar treatment, and I don't think anyone is going to do brain transplants in any of these futuristic scenarios.  And so I think the general — and this is not an ethical problem, it's just a utilitarian problem — is that most of the kinds of treatment decisions that we're likely to confront are ones that are actually not going to keep all of the systems going simultaneously, but they're going to put people in this debilitated state where the body is going, but the other things are not.  So that's, I think, the general — so it leads to something that is not my definition of what a good death ought to be, so that's just my simple-minded way of looking at it.

CHAIRMAN KASS:  More to Peter on this?  Ben.  Thank you. 

DR. CARSON:  I just want to briefly address a couple of things.  I think, first of all, what Peter was talking about in terms of general prolongation of life, we do have to keep in mind that it does have significant implications in terms of population, and in terms of jobs for the next generation.  I mean, it's not just an issue sitting on the table by itself.  It has many interlocking parts that we have to bear in mind.  But back to what Dan was talking about in terms of the economics.  I resonate very, very strongly with that, because we spend an enormous amount of the percentage of money that we spend in a lifetime in the last months of life trying to prolong people with relatively little benefit, particularly in terms of quality of life. 

At the same time, I think we have to be very, very cognizant that there's a difference between prolongation of life and alleviating suffering.  For instance, one group of patients that I deal with, patients with trigeminal neuralgia, and some of these patients are very elderly and have Alzheimer's disease, have a very difficult time articulating the excruciating pain that they're in.  But there are procedures that we can do that can eliminate that pain.  We should never, I think, hesitate to do those kinds of things in those people, but I think that's a very separate issue from just prolongation of life.

CHAIRMAN KASS:  Paul, sorry.

DR. McHUGH:  This isn't just to address, I guess, Peter's points, although they are important.  I want to come, as well, back to what Dan and Mary Ann said in relationship to the economics of things, and the services that we offer patients, and should ultimately offer all human beings.

I lived with this woman for 46 years who keeps reminding me about the importance of the poor almost every day I wake up, and says you ought to remember the poor.  And if I'm not remembering the poor in Baltimore, she reminds me of the poor in Africa, and there's other places; and so, therefore, I resonate vibrantly with these concerns that we have about what we're doing.

On the other hand, I also am aware, as Dan has expressed, as all doctors of Dan and my age remember, the dialysis issue — I remember John Merrill at the Brigham walking down the hallway planning, because there was no dialysis machine, not enough dialysis machines, and we hadn't yet gotten to this kidney transplant, to shut the machine off on a young man at age 18, and his head was down, and it was really awful.  But we have expanded that, and the economics now of doing dialysis has become less and less because of our capacity to concern ourselves with extending the care of those patients.  So the economic burden, the one, by the way, that Dan Callahan keeps raising — my response often is to say we do well in our kind of country, and our kind of organization as we make things less and less expensive when we say we're going to have to have it for everybody.  But it's not only in relationship to the dialysis experience, we've had it in all kinds of others.

The Polio epidemic of 1955, we decided we were going to take care of all those patients, and we had them in iron lungs.  You remember that.  And now that process of having these very awkward machines in play has now been replaced with these remarkably less expensive and more effective ventilator systems, which are extremely useful in all kinds of other ways that we have organized.

Even the AIDS epidemic — all of you must remember that when AIDS first appeared, the doctors and many of the sciences said look, this is a virus.  We're not good at curing viruses, correcting viruses.  Everybody, even at great centers like Hopkins, was very hopeless about the ability that we were going to have, but we were pushed hard by the particularly afflicted community, the gay community in particular, to do something and stop sitting around.  And now we've changed that.  We have these — I absolutely agree with you, they're expensive treatments.  And when you see the poor children in Africa who have lost their parents to it, it breaks your heart.

On the other hand, having them and accomplishing it was expensive, has made it possible for us eventually to get things which will be less expensive, and could go to other countries, and the process also of encouraging other countries also to develop the social system that could generate these  things for themselves.

I'm less concerned, in other words, by the advances of science here as they will reorganize our care, and bring certain kinds of conflicts to the fore, conflicts that will have economic and population significance, but I also agree with Dan that the life span is the life span.  I'm a doctor, and I'm not interested in increasing it.  Within the life span, I'm interested in removing disabilities, and directing my attention towards the correction of disabilities as they turn up, and eventually to have what Frank has mentioned, and I think Mary Ann once mentioned before, the One-Hoss Shay phenomenon, out to the thing where all of the things tend to fall apart together.

What concerns me, in other words, in fact, is not the science.  What concerns me about the best available care for patients if you go and talk with them, is that they tell you they can't get a doctor any more.  They can go from specialist, to specialist, to specialist, and get the unique science of today directed or not directed to them, but they can't get a doctor who begins with them at the beginning and walks the walk with them, and tells them what they're going to expect, takes them back from the specialist and decides what's going to happen further, and has the kind of meaningful relationship with that person that permits the decisions that will ultimately be made for the benefit of that patient who you lived with.

Now it used to be that there were plenty of such doctors around, but they're harder and harder to get.  Now it's not that I don't know plenty of people who do it, people like Dan are rare, but they're not as rare as hen's teeth.  There are a lot of people who do it.  The oncologists, for example, neuro psychiatrists, and plenty of other people do it, but we're not encouraging that in our specialist-oriented and science-oriented way, and we may not be supporting it.   We may not be supporting it either out of the culture, or out of the finances and the like, and I think that best available care more than anything else is going to demand us reminding people again of that.

CHAIRMAN KASS:  I want to say one tiny thing to you, Paul, and then use the occasion to turn to this other question which Mary Ann and Dan had started with, and I know Frank is interested.

I'm not sure that — I'll put it bluntly since we're friends.  I'm not sure that you feel sufficiently the force of the degree to which the very science that you rightly embrace is responsible for the kind of disappearance of the doctor that you are calling for.  That is to say, the specialization is precisely the result of the advance of knowledge, and the ability, in fact, to really do lots of things for people in a specialized way, and the Oslers, they're not absolutely gone, and he was rare as a hen's tooth in his time.

DR. McHUGH:  By the way, I agree with you on that.  I'm not disagreeing with you about that.  In fact, I for a number of years ran the Professorial Promotions Committee at Hopkins, and one of the questions that was often asked was would Osler get promoted today? And the real question was well, you better go back and look at what he did for exactly that reason. 

No, I'm not disagreeing.  I'm certainly not disagreeing with anything that anyone has said here in one sense.  I'm only trying to give it the context in which the practice puts it forward.  The scientists work with regularities.  Doctors work in the disorder of experience, where all kinds of factors, scientific, meaningful, cultural, economic are in play.  And if they have a relationship with the patient, the individual patient, they can carry people through with a sense of meaning, and a sense of the art of ultimately living the kind of thing that we hope for ourselves with their help.

CHAIRMAN KASS:  Someone want in on this?  Bill, did you have a hand before?

DR. HURLBUT:  I did, but if somebody has an intermediate comment, I'm okay.

CHAIRMAN KASS:  I was about to turn us to the other set of questions, the effects of resource.

DR. HURLBUT:  Then I'd like to speak before that.

CHAIRMAN KASS:  I'm sorry.  You want to comment before that?

DR. HURLBUT:  Yes.

CHAIRMAN KASS:  Please.

DR. HURLBUT:  Well, I just want to raise a rather vague notion, that maybe our problems with regard to the specifics of care and the over-extensions of technology will best be solved by keeping in mind the integrated whole.  After all, ethics is not just about preservation of life, but about living well.  And if we keep in the forefront of our mind all the goods of living well, then that will keep in balance a lot of things that could be exaggerated out of proportion.  And specifically, it seems to me that those are communal goods, and individual goods.

When I think of medical interventions of the kind we've been talking about here, I think maybe Dan would agree with me on this, oftentimes a medical intervention actually does some good for the patient, but also does something bad for the patient, since it alienates the patient from himself.  And the most obvious example might be making us increasingly into what's been called cyborgs with artificial parts. 

You can imagine that if you have an artificial heart, you may be pumping okay, but you may be slightly less than yourself.  You don't have quite the integrated endocrine responses to fear, for example.  Your heart doesn't start beating fast in response to the other indicators and signals from your body.

We could repair certain organs, but they're slightly less integrated to the whole of the person.  And slowly but surely the integrated physical being of the person is eroded.  There's, likewise, a parallel phenomenon, the psychological nature since we're a psycho physical unity.  The person gets alienated from himself to some extent, to the point where you could imagine producing a technological life extension that was, as you said, like an escalator that is continuing to roll but is getting nowhere in terms of personal process, and maybe even doesn't involve a memory or continuity of being with the person.  And the same thing, of course, can happen to the role of a person within the society.

I think what's going on here is a strange question that anybody who is involved in medicine is constantly asking himself; how do we balance the good of the given, of the natural world, with the obvious  imperative of healing and life extension?  And I think we have a big problem with that in our current society.  We tend to go on all fronts along with our immediate and superficial goals, often driven by pleasure and fear, but these can be superficial goals that if pursued with undue emphasis can alienate us from our deeper goods.

The question is how at the end of life do we keep in mind the larger over-arching integration and purposes of life in relationship to intervening powers of medicine?  Technology can certainly break the integrated connection that we're after, so then we have to ask ourselves that very, very hard question that we struggled with in this report.  Is there such a thing as a natural good in aging and death?  And although it's very hard to speak of, especially in a public document, what is the relationship to suffering in all that?  

None of us, at least I, for one, and I don't  think anybody in this room would want to have our society turned what "Brave New World" did, where people live in these kind of 25-year-old mentalities and then drop off the edge of a precipice.  We feel like there is a process to our lives.  We feel like there's meaning and purpose, that there's a source and significance to our lives, and a significance of our lives that transcends life itself, so what I want to say actually is maybe unhelpful, but I want to say that I think Dan's comment "I don't want to get theological", is maybe exactly the problem.   Maybe we don't specify this for an entire pluralistic society, but frankly, I think that that's what we need to do, is at least individually get theological in the broadly construed sense of theological, that we have to ask ourselves where did we come from?  What are we for?  How does our technology play into those purposes?

We certainly are in a love affair with technology, and it's certainly crucial that we try to preserve and sustain the mystery of life from being mowed down by the juggernaut of technology. 

CHAIRMAN KASS:  Thank you.  I want to turn to the other question, but I want to also thank Bill.  I think we are trying to do something very useful, albeit limited, in this particular document, but if part of our aspiration really is richer bioethics, we might, in fact, be in danger of contributing to some extent to deflecting the attention from this.  That was probably why I wanted this discussion to be had; questions of the meaning of the life cycle, the question of what is a good death is not the same as the question about when you should refuse life sustaining treatments, important though that latter question is.  And to the extent to which the ethical considerations are driven by those very pressing concerns, we miss an opportunity, in fact, to flag these larger kinds of questions, so I very much appreciate and sympathize with, and I'm concerned about whether what we've done, however useful, is actually adequate to the larger task, though it's not clear to me that those larger things are — we can legitimate such conversations, whether anybody but the people in the room would find them welcome is another matter, but I'm very grateful for that.

Let me turn to the question of — everybody is intuitively bothered by the inequities, not just of medical care, but of inequities generally.  What to do about it is another matter, and how to deal with it without making certain other kinds of things worse is a long subject.  They are political questions.  There are people who have been very critical of this Council for not taking up the subject of the effects of the distribution of medical resources.  Though they were not primarily interested in our actually exploring the ethical issues, they were interested in our taking a particular side on this and becoming advocates. 

I happen to think that this is a very important and difficult ethical question, but I'm not really sure how you set about doing it.  And if I were to say turn to my friend, Mary Ann, who is I think prescient on this subject of tension amongst the generations, a kind of forgetfulness that after all, all of us, God willing, get a chance to be at all stages of the life cycle and, therefore, declaring war on one stage against the other is just deeply dumb.  Yet, you have the AARP but you don't have the comparable equivalent for the children under five.  Even the ones with resources don't have people to speak for them, so the question is how might this Council set about trying to think about the ethical way, the kind of ethic for speaking about these things, and to do so not in a language you should be nice to your neighbor, but do so in some way that could actually — but to make it concrete and useful.

Is it possible to speak about the obligations between the generations in a way that has some kind of bite?  Is there a way to speak about the more limited question about how to set limits, more modest limits on the expenditures that here have been discussed in which lots of money seems to be spent for very little gain, and that robs funds that could be better used for other things.  If Janet were here, she would say so in spades. 

Now it's one thing to sort of issue a cry for the problem.  It's another thing to say how could careful reflection be actually helpful on this subject besides raising your hand and saying this is a terrible situation?  Paul.

DR. McHUGH:  Just a very minor qualification, but I think your formulation right near the end actually makes it way too easy.  You said lots of money spent for very little gain.  There's lots of money spent for a lot of gain, but nevertheless, the kinds of problems that we have.  I think that — 

CHAIRMAN KASS:  Let me take the correction completely.  And since you have the floor, and since ethics is your field, may I invite you to put your toe in this water?  Can a body like this actually say something on that subject?

DR. McHUGH:  Even though I wasn't named as one of the people for whom this was a primary concern, I'm supposed to say something.  Well, yes, a body like this can say something, but my own view and, of course, all views on this question are arguable and disputed.  My own view is that the question is to some considerable extent a political one; that is to say, there are always many more things that we need to spend our resources on than the resources will cover.  And it's very hard to find the level of reflection from which to say this is the way it must be done.  And I think to some degree these things do have to be fought out at a political level.

Now that does mean that your five and under category will not be speaking for itself, of course, in that political argument, and somebody else is going to have to do it.  Maybe part of the role of ethical reflection is to be alert to that fact, and be aware that somebody else will have to do that, so in that sense it seems to me there would be a kind of moral role to play.  But for me, anyway, I don't think it's possible to delineate what the right distribution of our resources would look like.  I think that has to be argued out.

The other thing I'd say is that however you work it out, you have to have some kind of micro/macro distinction.  In other words, I don't want my physician pondering whether providing care for me is the best way to serve the larger common good.  I would like my physician to think that I'm the patient, and  that's my doctor, and there's a certain kind of relationship at work there.

It's a different matter whether at the macro level we ought to think about ways of allocating resources such that maybe there's some kinds of care my physician just can't provide for me.  He does me no wrong if he doesn't provide for me what we haven't made possible to do.  But if it's possible and it's there, and it's within my means, or my insurance means, or whatever, I'm very reluctant to have physicians begin to think of themselves simply as servants of the larger good, and not of particular patients, so those are the several kinds of ways into the question that I'd take.

CHAIRMAN KASS:  Let me lean on you just slightly, if you don't mind.  I like the distinction between the macro and the micro, and I think these kinds of questions in so far as they're questions of policy really have to be social questions, and socially everybody understands that.  But if someone were to say to you, Paul, look — society has basically decided that we are misallocating our medical resources, and we want this Council to offer us ethical advice on Dan Callahan's theme setting limits.  Is there an ethical way to have a discussion?  I grant that the political process might not pay any attention, but would you think that there is a way to have a serious discussion, and to develop some kind of ethical norms or guidance in general terms that might help people to figure out what's too much, without saying so-and-so's life is not worth living or not extending, but as a matter of social policy, or if somebody came to you and said look, that's not for ethicists to talk about, and we shouldn't try.

DR. McHUGH:  Well, I never accept someone telling me that something isn't for me to talk about, so I wouldn't take that route.  I don't find the "how much is too much?" a very fruitful question at the level of particular patients.  And I wouldn't use the language of medical care here.  I'd want to talk about research. 

Dan Callahan has also pointed out that the NIH research budget is the one thing that we keep pumping more and more money into year after year, and that's part of what generates our problem, because if you got a new and better treatment, and you're my doctor and my insurance will pay for it, I think you better give it to me, not decide that there's somebody younger and healthier, and nicer who the community would be better served by our keeping alive.  So yes, I think we can talk about it, but I would start talking about research priorities rather than start talking at the level of medical care and how much is too much for particular patients in particular circumstances.  I want to start talking at the macro level.

CHAIRMAN KASS:  Or what Medicare should pay for.

DR. McHUGH:  I mean, certainly that's a legitimate topic, or at least some kind of lexical ranking of what it should pay for certainly there.

CHAIRMAN KASS:  Mary Ann, then Ben.

PROF. GLENDON: So given that these questions are going to come up in the framework of interest group politics with some groups not represented at all, we've always said on this Council, I think, that one of our aims is to try to enrich political discussions.  It's a very ambitious aim, and the question of allocation of resources, I think one very useful question that almost never gets asked, but that can be raised by a group like this is addressing each contending party for a piece of the pie.  Ask them to explain what kind of society their program is likely to bring into being, and ask them if that kind of society is the one that they really want to live in.  I think it's just a very helpful question to draw things out a few steps.  What probabilities are you setting in motion with these decisions, especially at the macro level?  But what are we going to do research on, just things that are of interest to the elderly, or other matters?  So just a way of framing the question I think is something that — we can't solve the problem.  We can't make the political decisions, but we've always said that we're trying to raise the level of the national conversation.

CHAIRMAN KASS:  Ben, and then Frank.

DR. CARSON:  Leon, I think it's not only a legitimate topic for us to consider, I think it would almost be negligent not to do so, because it's such an important issue for our society.  We have certain norms and expectations in our society.  For instance, we feel that everybody is entitled to shelter, to a roof over their head.  And we, as a society, go through great lengths to make sure that that occurs for the vast majority of people.  However, there are some people who go beyond that, and perhaps live in very luxurious accommodations.  We don't begrudge them that.  And by the same token, we need to begin, I believe, to look at certain types of care that are provided, and that are available. 

Certainly, there needs to be a basic level of care that is given.  If people want to go beyond that,  just like if they want to go beyond basic shelter, then that should be their responsibility.  It shouldn't be the responsibility of the society, number one.

Number two, I wonder if at some point there is a way that we can integrate into this whole cost issue the concept that one-seventh of our economy is based on healthcare.  I personally think that's way too much, but the reason that it is, is because we tend to be oriented towards sickness.  We want to fill up the hospitals, we want to fill up the ICU beds, we want to treat this, and this, and that.  And we don't spend anywhere near an appropriate amount of time dealing with wellness, which would save us an enormous amount of money.  I wonder if we have some obligation to bring that out?

CHAIRMAN KASS:  Very nice.  Frank.

DR. FUKUYAMA:  Well, I'm the one that thought that we ought to have a statement, which I'm glad has got into the report, that there's actually a moral case to be made for the government mandating the socialization of the costs and risks of long-term medical care.  We'll see if that survives in the draft, and I think it's a perfectly legitimate topic for a moral or an ethical discussion for the following reasons, and it really gets to the whole question of the moral arguments between the left and right in this country over the legitimacy of the welfare state.  And in this case, I believe that this particular extension of the welfare state is perfectly justified, for the following reasons. 

Americans are much more inclined than Europeans to not like social solidarity provided through central government.  Americans believe that for moral reasons, it is better to have people and families be self-reliant, and so when FDR introduced Social Security, one of the conservative arguments against it was that this would relieve families of a sense of obligation towards their parents or older people to care for them.  And, in fact, that is one of the consequences of state-provided Social Security.  However, I think that if you think about that, so in a sense a lot of the model that people have is that people ought to think ahead, save money for their own debility and take care of themselves without the government stepping in.

Now I think that that just doesn't work under present circumstances for a lot of reasons.  First of all, it's dependent on an old model of the family that just does not exist any more.  Privately provided healthcare was dependent on the uncompensated labor of basically women up until the revolution that took place in the 60s and 70s, and it is simply not realistic — and even in these Confuscian societies in Asia where that was actually built into the ethical structure of the society, that's all breaking down because of the changes that Mary Ann referred to in family structure, this dramatic drop in fertility, plus the greatly extended life times, and then the need in the case of Alzheimer's, 24-hour-a-day care over an extended period, five to ten years.  It is something that families simply cannot — I mean, the idea that families could provide this I think is just completely unrealistic. 

The other moral case that is made by conservatives against these kinds of government mandated benefits is the moral hazard one, that if you insure against something, you're going to get more of that bad behavior.  That was the case against Aid to Families with Dependent Children.  It insured against the risk of a single woman raising a child, and it encouraged more out-of-wedlock births because you now knew that you could raise a child without having to marry the father.  And I would say that this simply does not apply in this case.  There is no moral hazard involved in mandating the socialization of the risk against long-term medical care.  Nobody is going to get Alzheimer's deliberately because they know the government is going to protect them economically from doing this.   It's a pure genetic lottery as to who does it.

Now I think that there is a public policy dimension to this that we do not have to address, because there's lots of different ways of taking care of this.  The government could provide — right now, the current policy is really pretty defective, because right now what everyone does is they try to figure out how to strip all the assets out of their parents' bank accounts so that they can declare themselves bankrupt, and then qualify for Medicaid.  So, in fact, we are providing government insurance for this, but through a way that was never intended.  It's through a gaming of the system, so it's a very dysfunctional way of going about it, but you could either have the government provide this insurance directly.  You could do it as we do in the case of automobile insurance, where we mandate that everybody must insure themselves against the risk of liability and so forth.  Or at a very minimum, you can prevent the private market from doing what it would do without this kind of intervention, which is to try to cherry pick; use, for example, genetic information on who is likely to get Alzheimer's, and then raise insurance rates for people with that propensity.  And certainly at a very minimum, I would say that you should not permit private insurance to make those kinds of discrimination, so I don't think it's up to us to say what particular public policy ought to fix this problem, but it does seem to me that you can make a pretty straightforward moral case that this is one instance where there's a kind of public good that needs to be addressed that the private market and private individuals simply are not going to be able to take care of on their own. 

CHAIRMAN KASS:  Peter, take the last comment, and we'll take a break because we have guests.

PROF. LAWLER:   Let me just say something very quickly.  I agree with about 90 percent of what Frank said, and this afternoon, because we have guests, I will even say that our report points to certain kinds of public policies over others, but let's let that go until this afternoon.

CHAIRMAN KASS:  Okay.  Look, I think obviously we didn't exhaust any of the things we've talked about here, but I think there were things that were raised in this discussion that could come back tomorrow morning when we talk about future directions, and future activities of the Council, and be thinking about that and other things when we reconvene on that.  We've run five minutes over.  We'll take 15 minutes.  We'll start at 10 minutes to the hour.  Please be prompt because we have guests.