Bioethics Research Library at Georgetown University https://repository.library.georgetown.edu/handle/10822/503786 Transcripts of the President’s Council on Bioethics (PCBE) Meetings 2001 - 2009 The Bioethics Research Library is collaborating with Georgetown’s University Library to digitize, preserve and extend the history of Bioethics. Please tell us how this access affects you. Your experience matters. Visit us at https://bioethics.georgetown.edu/. Interested in learning more about President’s Council on Bioethics? You can visit their website as it appeared on the last day of its charter. There you can learn about the council members, browse their reports, and locate background materials. The website is hosted by the Bioethics Research Library and can be found at: https://bioethicsarchive.georgetown.edu/pcbe/ Materials produced by the President’s Council on Bioethics are government documents and in the public domain. When citing this document please note the source as Bioethics Research Library and the appropriate Digital Georgetown hyperlink Collection Permanent Link: hdl.handle.net/10822/559325 Home Meeting Transcript About Us Meetings September 11, 2008 Reports Council Members Present Transcripts Background Edmund Pellegrino, M.D., Chairman Materials Georgetown University Former Bioethics Benjamin S. Carson, Sr., M.D. Commissions Johns Hopkins Medical Institution Rebecca S. Dresser, J.D. Washington University School of Law Jean Bethke Elshtain, Ph.D. University of Chicago Daniel W. Foster, M.D. University of Texas, Southwestern Medical School Robert P. George, D.Phil., J.D. Princeton University Alfonso Gómez-Lobo, Dr.phil. Georgetown University William B. Hurlbut, M.D. Stanford University Donald W. Landry, M.D., Ph.D. Columbia University Peter A. Lawler, Ph.D. Berry College Paul McHugh, M.D. Johns Hopkins Hospital Gilbert C. Meilaender, Ph.D. Valparaiso University Janet D. Rowley, M.D. The University of Chicago Diana J. Schaub, Ph.D. Loyola College INDEX Session 1: Ethical Questions in the Reform of Medical Care Session 2: Conscience and the History of Moral Philosophy Session 3: Conscience in the Practice of the Health Professions SESSION 1: ETHICAL QUESTIONS IN THE REFORM OF MEDICAL CARE CHAIRMAN PELLEGRINO: Good morning, good morning. DR. ROWLEY: Good morning. CHAIRMAN PELLEGRINO: And good morning again. Thank you, Janet, but that's one way of getting attention, just say something. Thank you. Welcome to the Thirty-Fourth Meeting of the President's Council on Bioethics, and welcome back from your summer holidays. I hope you all had a good one. I want to take the first step, the official step, of recognizing the designated federal representative, Dr. Daniel Davis to my left. This gives us federal stature and legitimation, I gather, as well, and we're glad to have you with us, Dan, as if we could do anything without you. I want to also welcome two new members of the Council — I will only provide their names at this point. Background material is available elsewhere — Dr. Jean Bethke Elshtain on my left and Dr. Donald Landry on my right — no reference, I suspect, to your positions. That just happens to be accidental. So we expect you to cover the waterfront. This morning we pick up a subject we've been discussing on a number of occasions, and it has now been put into the form of an initial white paper. The subject and purpose has been to examine the ethical issues involved in health care policy formulation. The word reform was a little bit too ambitious, but rather where should be going at this point in our history with reference to health care which I need not point out is a subject of enormous interest to the American public at this particular time. Our aim is not to enter into a comparative study of any of the plans being put forward, but rather to step back and look at the ethical problems that should be faced by any plan and which might be used to examine and look at and judge any one of the plans as they're being discussed in the public arena today. The procedure we follow will have two of our Council members have been asked and graciously accepted the invitation to open the discussion: Dr. Rebecca Dresser and Dr. Diana Schaub. I would like to ask Dr. Dresser if she would be willing to begin the discussion. Rebecca? PROF DRESSER: Sure. I think that the paper does a good job of showing why viewing medical care as either a commodity or a right doesn't tell the whole or the best ethical story. At the same time, I wondered whether we had to present it in an all or nothing framework. I think that I like the idea of showing that medical care is an essential element of the common good and that's the most defensible way to conceptualize it. But I don't think it would hurt to kind of acknowledge that the other two views do have an influence and play a role in how people think about this, and we can do this without undermining the basic position. So perhaps we could say that they underlie certain popular ideas and judgments; for example, that no one should be without, at minimum, emergency care. If someone is hit by a car, that person has a, quote, right not to be left in the street to suffer, just kind of an ordinary understanding of that, and that on the other hand it may be okay to see some kinds of, quote, medical care as a commodity, frills like cosmetic surgery or even LASIK or something like that. So that's just a small comment on the framing of the analysis. And then a little bit of substantive comment. When I think about this problem, I see that there really is a pretty good general public ethical consensus that everyone ought to have at least a decent minimum of health care — that was the way the President's Commission put it in 1983 — and that this view can be defended using all kinds of different ethical arguments. So the question then is, why haven't we been able to put this general sense into practice, into policy? So I was thinking about maybe we could call it the hidden ethics of health care reform like we talk about the hidden curriculum in medical school where we teach all these things, but then the students observe how people really behave and learn a lot of often negative lessons. So if we look at health care reform, one problem would be for many people in the current system health care is a commodity, not necessarily the patients but for the other people who are the players like industry and hospitals and some physicians. So people who, in the current system, who benefit from that and have kind of a stake in the status quo, a financial stake, and their self-interest at stake prevent change from happening or work against it. We also see physician groups who are concerned about loss of income and freedom. For example, there is a fair amount of opposition to sort of making medicine more restrictive based on evidence- based judgments. And I agree there is some merit to that, but they're kind of fighting against any kind of restriction that might come with a broader health care plan. And often the interest groups kind of portray their views, present their interests, as if they are protecting the patient's best interests. So when you think about that Harry and Louise advertising campaign where the insurance companies were trying to protect their turf, but they pretended it as something that put patients at risk, and that was very persuasive. And then another barrier to change involves two patient interests, so people like us who have good health care coverage may have to accept something less so that more people can be covered. For example, the current employer-based health system has some unfairness in it, especially this failure to tax the benefit as income, and we all get a subsidy from that and it's probably unfair because people who don't have that coverage don't get it. But then on the other hand, as a former cancer patient, when people talk about putting all this stuff into the individual insurance market, it makes me nervous because I wonder whether I'll be able to buy something, a plan, that's affordable and has decent coverage. So I think those dynamics are preventing change from occurring, too. I think the paper discusses this implicitly and how you would just encourage bringing it out. When we think about medical care as a common good and a public good, we should talk about perhaps sacrifices or commitments that are needed to remedy the lack of access and to generate the political will to get something done. On Page 34, you talk about public health as a social good, and this is a quote. It says, "Sometimes, public goods, such as protection of public health, require individuals to make sacrifices that will not benefit them directly as individuals," and then it goes on to talk about quarantine and an earlier part talks about vaccinations. So I wonder if there would be a way to just talk about some individual contributions or commitments that the haves can make so the have-nots can benefit, and not necessarily in a preachy way but in a way that might make people want to make a sacrifice as we see sometimes in social life, and then also the contributions that we should expect of business and the medical profession in order to create a care system that really better meets our ethical responsibilities.