Role of a Textbook in Bioethics Education

Dr. John Lantos

The topic for this first afternoon session is the role of a textbook in bioethics education. We happen to have a textbook to stimulate the discussion, and we're going to pass around a few copies, one in each quadrant of the audience, so you can take a look and pass it on so you'll be able to ask informed questions. We have a stellar panel. I will introduce them briefly, and then everybody will... Peter Singer on my immediate left is Professor of Medicine, the Sun Life Financial Chair in Bioethics and Director at the McLaughlin-Rotman Center for Global Health at the University of Toronto. In 2007, he received the Michael Smith Prize as Canada's Health Researcher of the Year in Population Health and Health Sciences. He's Foreign Secretary of the Canadian Academy of Health Sciences. a fellow of the Royal Society of Canada and of the U.S. Institute of Medicine of the National Academies and the Academy of Sciences for the Developing World. He's also on the Scientific Advisory Board of the Bill and Melinda Gates Foundation Grand Challenges for Global Health Initiative. And for today's session, more importantly, he's the editor-in-chief of the Cambridge textbook of bioethics. Judy Andre is Professor Emerita at Michigan State University. Professor Andre's research pertains to ethical issues raised by globalization, especially in the context of public health. Her research focuses on the questions raised by commodification in the global context, what should be for sale, kidneys, gametes, research participation, and also on the relationship between economic systems and health. She is the author of the book, Bioethics as Practice, which was published by UNC Press in 2002. And the gentleman on the far left, I think needs no introduction, the Lindy Bergman Distinguished Service Professor of Medicine, Dr. Mark Siegler. Peter.

Peter Singer

Thank you very much, John. It's really humbling for me to be here with such a great group of people. And Mark, it's incredible what you've produced, and I just wanted to acknowledge the work that you've done in helping to train all of us and thank all the donors and sponsors of your work who might be in the room. It's fantastic what you've accomplished. You could just look around the room and see that. So congratulations.

Peter Singer

What I want to do in these very brief remarks is just give a few vignettes over the last 25 years that might help explain a little bit what's behind this textbook that's being used as a model here for discussion of textbooks in bioethics. So when I was an intern, and I was caring for a young woman with cervical cancer, and she was going to die. She had widespread metastatic cervical cancer. She also had a low level of phosphorus in her blood. And we sat there on rounds talking for about two hours about hypophosphatemia, 78 causes, 54 ways to approach it.

Peter Singer

But when it came to whether or not we were going to resuscitate her, there was no systematic approach. You know, we scribbled DNR in the nursing cardex and rubbed it out after she died and wasn't resuscitated. So to me, that taught me two things. One is that ethics actually matters very deeply in clinical care. And secondly, there was no framework to approach ethical issues in the care of patients. that was in any way analogous to the frameworks that we had to approach physiological issues and other sorts of scientific issues. And even if you thought hypophosphatemia was as important as death, it seemed to me that the intellectual focus with which we'd approach those two problems were different. Contrast that with another experience I had in my internship. I'm sure all of you had it. Called to the emergency room for a patient with heart failure. you could list the six underlying causes of heart failure, the 10 precipitating causes of heart failure. We had mnemonics like goddamn, general measures, oxygen, digitalis, such as it was once used, et cetera, that I still remember. So we had several rubrics and frameworks for approaching heart failure. But at the time, no such rubrics or frameworks for approaching end of life care. And of course, people with grade four ventricles, 50% of them die within a couple of years. So those are a couple of experiences from my internship that taught me about the importance of ethics in clinical care and taught me about actually the absence of frameworks, especially relative to physiological frameworks, where ethical considerations could actually be used to improve patient care. Fast forward now to the year 1988,

Peter Singer

I was here doing my fellowship with Mark. And my vignette there is Mark in his little white lab coat with a stethoscope around his neck, wandering around and seeing patients and wandering around and doing ethics consults. Of course, we were at the time reading the paper, The Legacy of Osler, that he'd written about 10 years before. And again, what you had there was the notion that ethics was very important at the bedside, could be used to improve clinical care. and that there were some frameworks. And at that time, we were using, and you probably still are, his four-part framework from another textbook, the clinical ethics textbook, in terms of approaching patient problems. So that taught me that you actually could develop frameworks and that you actually could do ethics at the bedside. It was, if you will, a subject of completion of some of the experiences in my internship. That same year, for those of you who were here at that time, you'll remember Stephen Toolman and Stephen's participation in case conferences and his focus on casuistry, on paradigmatic cases, on ultimate particulars. which taught me about how cases matter in learning bioethics. And so when you're flipping through the textbook that's being distributed, you'll see that each chapter actually starts with a series of paradigmatic cases. And later on in each chapter, you do have real frameworks with clinical approaches about what I should do. Fast forward then from the Clinical Ethics Fellowship. The year is now 1995. I was leading a bioethics center in Toronto. we actually brought in all different disciplines, philosophers, lawyers, religious studies people, clinicians, because all these different lenses could inform clinical problems. This is a place where I didn't take Mark's cautionary advice for humanists, and I take it we'll have a panel on that a little bit later, so I'll say nothing more about that now. And that informs, as you're looking at the textbook, the middle section of each of the chapters, where each discipline gives a perspective on a particular problem, like advanced directives, et cetera, the problem being addressed. So from those experiences,

Peter Singer

those are really the formative experiences that led to the way Each chapter, each topic in that textbook is presented, starting with the case, going into different disciplinary perspectives on the case, going into what's a clinical framework that can be used to address that problem, going into returning to the case about how those perspectives and how that framework can actually be used to help with the cases that started. So in a sense, it's a combination of cases and principles and clinical paradigms. But it was from those authentic roots that that arose. In the 1980s then, late 1980s, starting in 98, I started to edit a series of articles which also had that framework called Bioethics for Clinicians. And this 48-part series, 28-part series, which was published in the Canadian Medical Journal, is segmented by clinical topic. Consent, capacity, voluntariness, advanced directives, quality end-of-life care, et cetera. And that, if you will, was the trial run for the textbook that you see, because that was quite well received, and it was really just building on that. that led to the textbook. So in 2004, when Cambridge University Press approached me about editing a textbook,

Peter Singer

I was unsure. I'd had advice here from a long time ago that a textbook was a big use of time, and it certainly was. But then the vignette is a discussion I had in my office at the time with Sue McCrae. She told me to do it, so I did it. Those of you who know Sue will understand that. 2005 was a year of writing a contract. 2006, a year of writing. 2007 was a year of editing. And then in January 2008, the book that you see, those of you who are looking at it as it's going around, was published. And the book has 100 authors, and many of them are probably in the room. Just raise your hand if you authored or coauthored a piece in here.

Peter Singer

Yeah, so several of us in the room. And I mean, we were a little bit anchored because we'd started with the Bioethics for Clinicians textbook. If we ever do this again, we'll do a better job with that. There's 65 chapters in, I think, 10 sections. And so as you flip through it, there's a section on information problems, dealing with consent, capacity, disclosure, et cetera. There's a section on end-of-life care, which Jim Tulsky edited, advanced planning, substitute decision making, quality end of life care, section on pregnant women and children that John edited, one on genetics and biotechnology, one on research ethics, health systems and institutions, and public health ethics. One very interesting section, which maybe Sue can talk a little bit more about, on using clinical ethics to make an impact on health care, looking at systems thinking and how clinical ethics can go into hospital systems. Really, I guess, drawing a little bit, Al, on your work in the medical outcome study. earlier on, a section on global health ethics, a section on religious and cultural perspectives, because all too often the four principles, or however many of those there are, don't apply very well cross-culturally, and then one on specialty bioethics, anesthesia, surgery, et cetera, because the problems sometimes look different from the standpoint of specialties, and this is something Martin McNeely, who's there in the audience, who's a thoracic surgeon, taught me. So that's essentially the anatomy of the book. What happened after January 2008 was

Peter Singer

I lived the experience of the poet John Ashbery, who said, writing a book of poetry and expecting a splash is like dropping a rose petal in a well and listening for the splash. And that's actually exactly what happened. So then I went into marketing mode. And I went on to Facebook. And I was going into all these Irish medical students, Egyptian L. Ames University medical students, and tell them, here's this textbook. I was using social media. And then one day, I even went to, there's about 120,000 people on the House Facebook site, the TV show House. So I did the same thing there to really understand what Dr. House did last night. You need to have a look at this textbook. And then I got a message from Facebook saying that if you do any more commercial marketing, you'll get kicked off of Facebook. So that was the end of my social marketing career on Facebook. Then, of course, there's a series of reviews that came out, about 10 of them. All the good ones or all the best parts of the bad ones are on the Cambridge University website, Cambridge University Press website. I'd encourage you to read them. I learned how stupid people can be in some of the other parts of the reviews. And those, luckily, are lost in the bowels of the internet. And you'll never be able to find them. And so there's this very interesting experience of the reviews coming out. In terms of the positioning of the book, I think You know, it's different from Mark's book, Clinical Ethics, which is really a four-part framework, mostly in the following way. I don't think you can have a single framework to apply to different clinical ethics problems, like end-of-life care, pregnancy, et cetera. At some level, you can, and it's a very useful way of learning. but just like there's a framework for heart failure and the underlying causes of heart failure. And that's different from the framework of liver disease and the underlying causes of liver disease. It seemed to me that we needed specific frameworks for different ethics paradigms. So that's how it's different from the clinical ethics book. It's different, and I think they're actually both very useful and complimentary because actually, if you drill down on what I mean by framework, at one level, there is a framework that can cut across. And then as you get into the cases, probably you need more specific frameworks. In terms of Beecham and Childress, of course, it's completely different because this textbook starts in the clinical realities and moves towards the abstraction and then goes back to the clinical realities with a clear focus on what would be your approach. Beecham and Childress obviously clusters things by the philosophical principles and then goes to the clinical realities. The other difference is that Beecham and Childress textbook probably is sold about a million times as many copies as ours had. So there's a bit about the positioning, but I think Mark put the issue of positioning best when I was in his office four months or so ago here for a global health thing. And I was sitting in Mark's office and as usual, there's papers all over the place and just a mess. And Mark pointed to a pile of papers and he said, and it was about this high. And he said, you know, I've always believed that your textbook is very foundational. And I said, well, Mark, thank you very much. I really enjoy that. That's a very nice compliment. And then he started shifting some of the papers away and moved some of the papers. And it turned out that he had the copy of a textbook, my textbook that I sent him, at the bottom of this pile of papers, holding up this pile of papers. So he said, you see, it's foundational. It's the foundation of this pile of papers on my desk. So I think he probably best captured the positioning of this textbook. But in closing, let me just talk about where we are in the present day, without kidding around too much. I think what these 100 authors have produced, and I should also mention Adrian Veens, who really helped to pull all this together. I think what these 100 authors have produced is actually a clinically very valuable textbook. I think John's going to raise some questions in his talk about the role of textbooks generally. And there was certainly a different reception from this very similar series of articles available on the internet that I had edited compared to a textbook. But I don't think this textbook has yet fully reached the audience of people who might benefit from it, if I could say so. And I think that poll that we had at the beginning shows that. So I've brought six books down. And they're circulating. Just raise your hand if you're just looking at one now in this quadrant. It's right there. And you got one there. You got one there. You got one up there somewhere circulating.

Peter Singer

You're kidding. Oh, well, there's already four of them. There's already one of them stolen. Anyway, what I was... There's one coming. But as you're looking at that, where I was going to go either a little bit later in this session, and there is no later in this session, or what John's agreed to do, there's two ways we can go here. We can look at the textbook and say, oh, in this chapter, you should have changed this principle to that principle. And, you know, we accept all that. Just email those sort of critiques along. But where I'd like to focus actually is on the issue of dissemination. You know, you've got 100 people, many of them in the room here, who have really contributed something that I think is very worthwhile. And because of the dynamics of getting the word on textbooks out, I don't think the word has got out to the point where people who would be able to find use in this, and we'll see from the other speakers whether what I just said is true, actually know about it or have been able to make the decision about whether they want it or not. So what I'm gonna do is with these six things in the discussion period, we'll have a little raffle for those of you who make one undertaking, any undertaking to help get the word out a little bit on the textbook. And anyone who mentioned something that they will do, first six people get a free textbook. And with that, I'd just like to say thank you very much for your attention. What I've really tried to just do is sketch some of the

Peter Singer

animating ideas behind the textbook. I actually think they're sound. I think the core issue I'd like to leave you with is just like the series, Bioethics for Clinicians, here's a textbook that I know I produced, and I think it's the same with the sort of 100 authors. We produced it with the motivation that ethics is important for clinical care. A structured approach to ethical problems can help improve clinical care. And a single resource whereby one can go for those structured problems is a useful resource to help improve clinical care. So if you ask me why I did this, my glib answer is because Sue McCrae told me to. My less glib answer is because I was committed to trying to improve the care of patients. And it's because of that, actually, that I want to focus in a little bit on the dissemination issues. Get your input both on the book and on its dissemination. And I thank you very much for your attention.

Judith Andre

When I picked up this book and looked through the table of contents, I saw a lot of familiar names. And it prompts me to give my own set of thanks, brought back memories of a wonderful year at the JCB in Toronto. And for that, I thank Peter Singer and Sue McCrae. And for knowing Sue McCrae, I thank Barry Mahold and Mark Siegler for a wonderful year seven years before here in Chicago. A lot of those names are Canadian. And I think that has something to do with the point that I'm going to make here. They have the luxury of being Canadian. How do you get 500 Canadians out of a swimming pool? You make an announcement. You say, would everyone please leave?

Judith Andre

In contrast, I'm an American, an anguished American, as if you were here for the health insurance reform panel yesterday, or if you simply are alive and in the United States, you know why I'm pretty much in agony. I'm in a country where people on Capitol Hill can say unblushingly, I'm a man, why should I pay for maternity care? I'm young, why should I pay for anybody who's old? And so on. These are painful days. I think something good will happen, but something sort of good may happen. But it is a very different country. And so that's going to have something to do with my responses here. The other context or positioning that I want to make is that most of my teaching energy over my decades of teaching in higher education It's been at the pre-baccalaureate undergraduate level. I teach a course with a philosophy designation in a liberal arts curriculum. And that's very different than teaching clinicians, which I've also done because I've spent almost 20 years in a medical school. But looking at the book and thinking about what to say about it has made has crystallized for me questions about what the difference is and what the difference should be.

Judith Andre

I'm going to draw from a book of my own the argument I make in Bioethics as Practice where I tried to pull together

Dr. Mark Siegler

the

Judith Andre

huge variety of activities that we in bioethics do, from sitting on national commissions or IRBs or teaching medical students or speaking to the press or doing research or whatever. It's a huge variety. What I argued is that what we are trying to do is engage in moral development for ourselves in conjunction with the people we serve. And I defined moral development as moral perception, moral reasoning, and moral action in all of which we can always get better. So to start with the first, what I mean by moral perception is being able to see the good and to see when goods conflict. And then you go to the second step, moral reasoning, trying to sort out what to do with the conflict. And what I mean by perceiving the good is seeing not only persons, and in that I think seeing patients as persons, I think bioethics has made major steps. There's a whole lot of that in the literature in many different ways. We've also made a lot of steps in seeing persons as encultured, as embodied in families, as in sets of meaning and symbol and so on.

Judith Andre

I think we've made relatively little progress in noticing that we are also always in systems, fairly formal systems, as well as informal ones, and that those make a big difference to life. They can be helpful. Well, they are crucial. But they can also be very, very hindering. That's the area known as organizational ethics. And I think that we've done really, really very, very little in that. When I picked up this book and just opened it at almost any page, it was with pleasure. 60 chapters, I think Peter said, a huge variety of topics. And some of them just spoke to me greatly. I was very pleased to see that there's a chapter there on whether one should engage, how one should respond if one is complicit in some way with military torture of prisoners. That's very, very important. I was really pleased to see a chapter on public health. These are all very short chapters. There's a wonderful chapter on pharmacy ethics and it's one of the most rounded of the chapters. Full disclosure here, just as none of you has read the 2,000-page bill that the House passed, I haven't read this 500-page book either, but I've read sections of it here and there.

Judith Andre

There's a section on rural health and in a chapter on rural health. And one of the things that's nice about that is it talks more than the others that I saw on how you could have two roles and conflicting role responsibilities. If you're, for instance, a member of the school board and your patient is an impaired teacher. No absolutes will do there. And I thought that was quite realistic and quite important. There is a short section on organizational ethics and on community health. And I'll say a little bit more about those later. But I do wanna talk about the kinds of things that I think are still missing, even in a book as comprehensive as this, and always under this rubric of moral perception. of noticing that something is good or that goods are conflicting.

Judith Andre

There is, I think, essentially nothing on conflicts between doctors and nurses. And by the way, I want to congratulate and thank Paul Helft for his work this morning, which highlights the experiences of nurses. When I first started in this field, I thought doctors were the bad guys and nurses were the good guys. And it was a question of doctors mistreating nurses. But eventually I was brought around to realize it does go both ways. And I tried toward the end to talk in some of my professional settings about, you know, can't we all get along? But I made no progress. And I would really like to see that topic, that inter-institutional topic, dealt with in much greater detail someplace. And whether it should be this book or not, that's another question. Hospitals as gossip factories. That's not a feedback, right? Okay. I think HIPAA has made that better, but it was an astonishing recognition to me when I first started to work in hospitals, how much everybody knew about everybody else. And I can give you lots of stories there. Going to a specifically American context, what's the obligation to do pro bono work? I don't see that addressed. almost at all, although there's a

Judith Andre

graduate of the McLean Center who does regularly bring that up, and his name is escaping me, but Minnesota ran for Congress, you know who I mean?

Dr. John Lantos

Yeah,

Judith Andre

but he's about the only one who does, and in the American context, that's gonna continue to be, I'm positive, a very important question. And then, And you're going to ask, I ask, does this really belong in a textbook on clinical ethics? But I'd like to see it addressed somewhere, somehow. And it's the question of taxes and being willing to pay taxes because it might help someone else. It has distressed me as an American that the only way any kind of health insurance reform could be proposed is framing it by saying nobody's going to lose anything. To me, that's shaming. But it is, I think, a political fact in the American context that that's the way things have to be framed. So a different way of asking that is most of this, like most of bioethics, is aimed at clinicians running into difficulties in the care of individual patients. And we need, that's where we started, that's where we're strongest, but we really need to move further than that. The clinicians are not only clinicians, they are also colleagues and they are also citizens. And I think that each one of those carries moral obligations with it and might be well at least touched on in any bioethics education.

Judith Andre

Okay, moral perception. So I'm saying there's a huge range here, but I would make it still broader, I think. Moral reasoning, thinking through conflicts once you see them. Now here is where the book is most different from anything that I would use in a pre-baccalaureate liberal arts course. There certainly is material in every chapter to think about. It's well put, it's relevant. It can't be deep, you know, not in having a book that's 500 pages rather than 2,000. The book is flexible in that there are references within the chapters to longer treatments. Srinivasan argues that I think that the United States should be giving one or all country, all countries should be given 1% of their GDP to Nepal but not to Thailand.

Judith Andre

So that's kind of intriguing, and you want to know what's the whole argument there. And there's a bibliography that if you were so inclined as a teacher, you could do it. You could follow that up. But it's not there. There's not much conflict of reasoned positions within any of the chapters. And so, you know, the big question is does there need to be? Certainly in an undergraduate liberal arts course, there needs to be no question. But does there need to be for clinicians? If we have to sacrifice something, is that perhaps the right thing to sacrifice? I would prefer, I think, to have a few more concepts explained, a few more principles evaluated, a more theoretical description of justice at some point. I was struck yesterday when Stacy Lindau spoke about this wonderful program in Southside Chicago working for justice in Southside Chicago. She had absolutely no conceptual resources for talking about justice, none.

Judith Andre

But the question is, did she need it? She's doing such good work, and I think I think there's a double-barreled answer there. She does not need it to do such good work, but she might need it if she's talking to funders or to a wider audience. She doesn't need it to do her work, but I think she needs it in order to talk about her work, enlist support for her work from certain kinds of audiences. And of course, as a philosopher, I know bits and pieces of 2,500 years of discussion of justice, there are a lot of things that could be said. It also struck me this morning, as well as yesterday, that when economists speak, it was only the philosophers who could engage them, with one exception, I think. See, that was very, very interesting. And I think it's a shame. I would, again, speaking as an American worthy, rhetoric of the market is overwhelmingly hegemonic. I think it's important for anyone who's making any sorts of important decisions to be able to deal with that. To give you just one example, and there's a lot more that could be said, but one of our, Amir,

Judith Andre

I think. Anyway, really, really nice presentation. And he said that the economist's way of thinking is like the Newtonian way of thinking about ideal gases or ideal motion. You take the pure case and then you see what's interfering with the pure case. What's fascinating about that is that the ideal market for an economist is not just a description. It is, in fact, a deep normative commitment to the idea that all that we can say is good is the satisfaction of individual preferences. Everything else, like all of Dr. Silvesi's talk this morning, but many things in between that and almost all of almost anybody's talk this morning,

Judith Andre

there's no language for it. There's no way to talk about it. There's no way. The fact that, I would say the fact that we should not allow old people who are poor to die for lack of medical care can only be expressed as social preference. In other words, the reason that's bad is because he doesn't want to die and the rest of us don't want him to die. There's no way in the language of economics to say, It's simply bad for people to die avoidable deaths. There's a whole Aristotelian language that Sen introduced to economics and which hopefully, along with behavioral economics, will change it. But my point is, my point is that I think deeper conceptual work is really important, even when you're focusing at practical clinicians in training. But I could be wrong about that. I just wanted to make the strongest case I could. Certainly when I'm talking about graduate education in the humanities or undergraduate, then I don't bow. And finally, moral action. This book is practical. Each chapter starts with the case and ends with the resolution of the case. It leaves open some places to think. Because it's not saying this is the one and only thing that should be done. It's what was done. There's some defense of it. The right teacher could take that and say, do you agree? Is that what should be done? And so on. It's very practical in that sense. But once again, speaking as an American, there's another kind of moral action that is

Judith Andre

that I don't see in the American public stage, and that is the ability to talk civilly and respectfully to people with whom we disagree. Richard Epstein yesterday was disgusted at the level of discourse. I am also disgusted, but from the other end of that particular spectrum. The degree of ignorance, the degree of disrespect has been painful and astonishing. Now, in any kind of bioethics, we model talking respectfully, students do pick that up. But I would like it to be more explicit. And in fact, I would like the kind of thing that Lainey was talking about this morning when she said, was talking about talking with parents. And one of the things she had a little methodology there was resist the writing reflex, the reflex to say, you're wrong, I'm right. Let me show you how you're wrong. a nice piece of advice. And Lainey, I hope it gets me through my own Thanksgiving dinner. Thanks.

Dr. John Lantos

I do, but yeah, you can put them on now. It's, of course, great to be back in Chicago. And being away, it's interesting to view the McLean Center from afar. and to realize what a profound impact the center has had on bioethics throughout the United States and throughout the world. It's truly a national treasure made possible by the efforts of Mark, the McLeans, the entire advisory board, and the stellar faculty. So I just want to add my thanks to all the other people who have said thanks for the great work that you do, Mark.

Dr. John Lantos

It is also interesting to come back here and speak. I give a lot of talks and usually if you're giving a talk at CME and they ask you for a title and then three objectives and sometimes study questions and conflict of interest forms. Here you get a call from Mark in like April and he says, will you talk? And you say, yeah. And then the program arrives in October and you find out your title.

Dr. John Lantos

It's a little like playing Jeopardy.

Dr. John Lantos

you get the answer and have to come up with the question. Some people even seem to think they make up their own titles and just forgot what they were, but I don't think you did. So my title is something about pediatrics, but I'm gonna talk about why a textbook, especially because textbooks are clearly obsolete. I know that because I had a conversation with Peter Singer about five years ago at a McLean conference, Actually, I think it was at Rose's Blues Bar afterwards and told him I was working on a new book. And he said, books are obsolete. And I'm not a philosopher, but if books are obsolete and if textbooks are books.

Dr. John Lantos

Although I start off with that claim with a little fear that I will start to sound like Richard Epstein. These books are the most calamitous development in academics and moral philosophy in the history of Western civilization. There are so many things wrong with them that I could not possibly enumerate them all without taking another breath.

Dr. John Lantos

And I'm only saying such nice things because I'm trying to be tactful.

Dr. John Lantos

But still textbooks are obsolete and interestingly people keep writing and publishing them and people keep asking people to write chapters and they're assigned in courses and it's interesting to think about what they do. Why a textbook in anything? I think of textbooks both as things you use in courses in medical school and also things that are chained down on the counter in the emergency room in the clinic. And when you need a piece of information fast, you go to the textbook and look it up. But nowadays, I wonder how many students actually buy Harrison's or buy Nelson's or buy these thick tomes as opposed to using their PDAs or getting on the net and getting the information they need fast. And the question I think about a textbook and this idea that Peter put forward of a framework to help people think through problems in a structured way is, How does a question like how do we go about getting a DNR compare to a question like what's the dose of dopamine?

Dr. John Lantos

The analogy makes sense up to a point, but then it sort of falls apart for all the reasons Judith Andre was talking about. You really want more than knee-jerk responses. You don't want to teach people so much algorithms. You want to teach people something more like moral reasoning. But I think figuring out what sort of data storage and retrieval system works best for either getting people frameworks of ethics or teaching people to think through a problem will be an interesting question for future research. But let's say people do use textbooks, want a textbook of bioethics, and have to go out on the market and talk about them. So I'm going to go through some of the stuff that Peter talked about a little bit, the comparisons of four textbooks that are out there. and imagine that you are a rational consumer and you're trying to figure out which one of these is going to be the most useful. And I put the abbreviations that I'm going to use. Well, you could start by just looking at how big they are. Clinical ethics is the shortest of the bunch. The principles of biomedical ethics a little longer. The Cambridge textbook weighs in at 554 pages. And the Oxford handbook of bioethics is by far the longest, nearly 1,000 pages. So if you want more ethics, you'd clearly go for Oxford. If you want less, you'd stick with clinical ethics. But maybe you'd look at weight

Dr. John Lantos

instead. Here, interestingly, the Cambridge textbook, even though it's much shorter, is almost as heavy as the Oxford. But that may not be the best measure either. Price, of course. clinical ethics is the cheapest. The Cambridge textbook, at least on Amazon this morning, the most expensive. And Oxford, even though it's longer, is a little bit cheaper. But really, if you're looking for value, what you'd want is dollars per pound.

Dr. John Lantos

And there, interestingly, clinical ethics is really, it's like buying truffles.

Dr. John Lantos

And

Dr. John Lantos

again, the Oxford book comes out as the best dollar value. Or you could look at what other people are buying. This is the Amazon sales ranking for the four books. Clinical Ethics, at just the 22,000th best-selling book on Amazon, is far better than the other three. And Cambridge, as Peter noted, is lagging behind. This may not be the best measure, though, The number one bestseller is Going Rogue.

Dr. John Lantos

It may be that being farther down on the list is really where you want to be. What if you looked at the content of the books? These are the sections in the table of contents, Clinical Ethics. Everybody's familiar with the sort of four box model. The Principles of Biomedical Ethics, also true to its title, deals much more with theoretical stuff. The Cambridge book, Peter went through the section headings, and you can see it's much more topic-specific, whereas the Oxford book sort of straddles, I think, the theoretical and the clinical in ways that Cambridge doesn't. And one gets the sense that these books are sort of looking for a framework to organize the field of bioethics, and haven't settled on one. the way I think clinical textbooks have. I mean, if you compare different medicine texts or different pediatric texts, they have the organ system specific things, they have the physiologic things, but they all look pretty much the same. These all look very different. So the question of what the organizational structure says about the way we're thinking about frameworks and bioethics is interesting as well. If you drill down a little deeper, Amazon has this nice feature, I don't know if you've seen this, the SIPs. I love the acronyms that sound sort of like what they're describing. You just want to take a sip of the book. Statistically improbable phrases, but these are sort of the things in the book that make it unique. Clinical ethics has a lot of stuff about futility, end of life, terminal sedation, brain criteria, decisional capacity. For the principles of bioethics, again, much more

Dr. John Lantos

Here's the Cambridge book. You can see with each successive one, you're getting more statistically improbable phrases. The Oxford one has some phrases I'm not even sure what they mean. Causal forks.

Dr. John Lantos

But that might help you decide either if you're looking for a book for undergrads, medical students, or practicing physicians, or if you're looking for specific topics, which of the four books to go to. Bigger books have more sips and more themes. There's no agreement on the organization or the contents, no agreement really about the balance between theory and practical advice, this tension about whether we're teaching people to think or giving people answers to practical problems. If you think about these ethics textbook versus medicine or peds textbooks, as I say, they're less uniform in content. They have a different spectrum from the theoretical to the practical with much more, I think, theoretical work in the ethics books. And the question then of who's going to read them and how they're going to use them, I think is an important one. Are they books for students or perhaps teachers of bioethics? I was interested how many people say they want to own this book. The question is, do you want to own it to read it? Or do you want to own it because you think you should have it on your shelf? Or do you want to own it because you're going to rip off chapters and copy them to assign to your students? Or what is the purpose? Clinicians,

Dr. John Lantos

whether a clinician would pick up this book if, say, you're a neonatologist called to the delivery room at 2 in the morning, look up the neonatology chapter quick to see about resuscitation. Or if you have a Muslim patient and You want to prepare yourself to go into the encounter. Are you going to look up the chapter on Muslim bioethics before you do that? Or if you're a policymaker and you want to know where you stand on stem cell research, will you turn to a bioethics textbook? It seems that all of these are sort of unlikely uses of these books. So the question of how they work, do they tell people what they should do? Do they tell people what they actually do? That is, are they descriptive? do they help people think about what they should do, or do they help people understand what it is that they're doing, is an interesting question. The more prescriptive they get rather than descriptive, the more controversial they are, but the more controversial they are, the better ethics I think they are, because everything interesting in ethics is controversial, and the less controversial it becomes, the more it turns into policy.

Dr. John Lantos

But I think the question that Peter asked about how do you improve the care of patients as the goal of this may be the wrong question to ask. And a better one might be how do you make a good doctor? That is, if these books are about ethics, they may have a slightly different target than books that are teaching facts. And then the question is whether studying ethics is the way to do that or whether it's to have been raised right, choose your parents wisely. whether it's the admissions process, selecting based on something, maybe emotional intelligence, whether it's role models and the whole apprenticeship approach to medicine, whether it's all the sorts of economic incentives that we were talking about today. If you pay people to get palliative care consults, maybe they'll get more. And that might be more effective than reading about why palliative care consults are right. But let me finish with this question then. students could just read one thing, and you were going to assign something that you hoped would make them a better doctor. Would it be a textbook of ethics? Would it be short stories by a physician poet like William Carlos Williams? Would it be a key legal decision about end-of-life care? Would it be some libertarian philosophy about autonomy and the freedom to choose? Or Sam Shem's House of God? Maybe give them the first season of House on a DVD. Atul Gawande's complications, maybe the death of Ivan Illich, or maybe the Book of Job. But I think the question of which of these you think makes the best doctors might answer the question about what

Dr. John Lantos

the usefulness of a textbook compared to other approaches might be. Thanks.

Dr. John Lantos

That was a

Dr. Mark Siegler

lovely talk. In 1892,

Dr. Mark Siegler

William Osler

Dr. Mark Siegler

published his textbook of medicine.

Dr. Mark Siegler

It was one of the first texts that organized internal medicine as an intellectual discipline. Here's a picture of Sir William at his desk.

Dr. Mark Siegler

I hesitate to say at Oxford rather than Cambridge.

Dr. Mark Siegler

What? He's Canadian. And here are some well-known pictures of Osler at the bedside. And the thesis of my talk today is that between the publication of Osler's textbook in 1892 and the foundation of the Rockefeller Institute in 1901, to the emergence, the serious emergence of the NIH in 1946. You had a span of about 52 or 54 years that there was in some way a relationship between these three events, Oslu's textbook, the development of the Rockefeller in 2001, and then the creation of the large-scale NIH that we've come to to appreciate post-1946. It was five years after the Osler textbook was published.

Dr. Mark Siegler

This is actually the fourth edition, but it was five years after the 1892 book that Frederick Gates, who was John D. Rockefeller's closest philanthropy advisor, spent his summer vacation on Martha's Vineyard, reading the entire thousand pages of the Osler textbook. And in his autobiographical memoir, Gates, this man, the philanthropy secretary recalls, and now I'm gonna quote Gates. This is a very important quote. Do I have a, oh yeah, good. I saw clearly from the work of this able and honest man that medicine had, with few exceptions, no cures, and that about all that medicine up to 1897 could do was nurse the patient and alleviate to some degree the suffering. Beyond this, medicine as a science had not progressed. When I laid down the Osler book, I had begun to realize how woefully neglected in all civilized countries, and perhaps most of all in this country, had been the scientific study of medicine. Well, Gates returned from Martha's Vineyard to New York, and he laid out his views about the tragic state of medicine in the United States and worldwide.

Dr. Mark Siegler

in a memo that he wrote to Mr. Rockefeller in the fall of 1897. He pointed out in that memo the great usefulness of the Koch Institute in Berlin and the Pasteur Institute in Paris, and he urged the development of a parallel American Research Institute. Importantly in that memo, based on this material that you see up on the board now, Gates said, don't invest any more resources in clinical care. Don't invest resources in medical education. Put your money where it has to be into scientific research because essentially of the primitive state of medicine that Gates detected through his reading of the Osler textbook.

Dr. Mark Siegler

I want to step back just for a moment to consider the early prehistory. This is Koch Institute and the Pasteur in Paris. I want to consider the early prehistory of the Rockefeller Institute because it's tied in with the University of Chicago. The University of Chicago was

Dr. Mark Siegler

The great benefactor was Rockefeller. The first president was William Rainey Harper. And Chicago opened in October of 1892, just coincidentally the same year that Osler published his textbook. And under Harper's leadership, the university rapidly expanded in Hyde Park. And part of Harper's early vision, certainly by 1894, two years after the university opened was to begin a medical school at the university. There were, however, two competing models for this medical school.

Dr. Mark Siegler

The first model was a fairly conventional model for the 1890s. In that approach, the University of Chicago, with its great departments of basic science, would affiliate with the Rush Medical College, which was the oldest and most distinguished clinical medical school in this region. And Harper began discussions with Rush in 1894. And these were discussions that were strongly opposed by Mr. Rockefeller and by Frederick Gates, the philanthropy secretary. So that was one model. The second model, which was the one that Rockefeller and Gates were urging, was to be very different from the conventional medical school and would be heavily based on research and scientific investigation rather than on clinical care. To indicate that Rockefeller, I'm sorry, that Harper got Rockefeller's message, I'm going to quote from Rockefeller's commencement, I'm sorry, from Harper's commencement address of 1897 that he gave here at the university. And here's the quote from the 1897 commencement address.

Dr. Mark Siegler

Yeah, this is part of the quote. What is the greatest single piece of work which still remains to be done for the cause of education in the city of Chicago and in connection with the university, a school of medicine? And here's where this quote picks up. I do not have in mind an institution which shall devote itself merely to the education of a man who shall be an ordinary physician, but rather an institution whose aims it shall be to push forward the boundaries of medical science, one in which honor and distinction will be found for those who make contributions to the cause of medical science, one from which announcements may be sent from time to time so potent in their meaning as to stir the whole civilized world. So Gates and Rockefeller were hoping to establish their new scientific institute at the University of Chicago. And here is what Gates reported. I take some of this from a book published in 1964 on the history of the Rockefeller Institute. Here's what Gates reported in appendix one of that particular publication. This was in a private memoir that Gates wrote to his own records. a memoir which was not published, actually, until that 1964 book. And here's what he said, quote,

Dr. Mark Siegler

our earliest conceptions associated the proposed medical institution with some great institution of learning and with some great medical school. Mr. Rockefeller was interested in the University of Chicago as its founder, and it was in his mind, as it was in my mind, that the institution of research would be associated, if the ideas were ever realized, with that young and flourishing institution. Unfortunately, President Harper eventually sided with the conventional model of a medical school, signed an affiliation with Rush, deeply upsetting Rockefeller and Gates, who promptly withdrew the offer of the new scientific institute.

Dr. Mark Siegler

Gates wrote on that point, I have no doubt Mr. Rockefeller would favor an institution scientific in its investigations. The University of Chicago should reserve the great weight of its influence, authority, and prestige instead of bestowing the same gratuitously on Rush Medical College. Such a scientific institution would have to be endowed and would run on a far higher principle than the principle of Rush College. or any other of the ordinary institutions. But from that time forward that Harper affiliated with Rush, Mr. Rockefeller said Gates, quote, never associated the proposed scientific institute with the University of Chicago. It was offered to Harvard the following year in 1898. And when Harvard turned down the Rockefeller, they formed a new board in New York a separate independent board, which launched the Rockefeller in New York in 1901. And that was the first year of operation. I show you a picture of the East River and where the Rockefeller was situated in 1920.

Dr. Mark Siegler

I now turn to this final part, the Rockefeller Institute's a relationship to the NIH. And the main point is sort of made in Richard Brown's book on Rockefeller's Medicine Men and on this wonderful book by Steven Strickland on the origins of the NIH, Politics, Science, and Dread Disease. I think the Strickland book came out in the late 70s. But Strickland says, or first I should say, Brown says, that up until World War II, private foundations were the leading force, aside from the medical profession, in shaping the direction of medical research and ultimately medical theory and practice. By 1940, the Rockefeller philanthropies alone had contributed more than $161 million to medical research and medical education. Strickland says pretty much the same thing in his book, it was accepted as natural that the private side should dominate. Rockefeller, Carnegie, Hooper, Sprague, and other private research organizations and private foundations giving money for biomedical investigation. The private sector was expected to support medicine and medical research. In fact, in 1938, the public health services budget, research budget, amounted to about $2.5 million.

Dr. Mark Siegler

The NIH got about 600,000 of that. And even by 1950, the NIH research budget was only $28 million. The private sector was still bearing considerable brunt. So in 1940 and 41, the Public Health Service, NIH, had a research budget of a quarter of a million dollars. By contrast, in 1940, the private foundations were contributing $4.7 million, roughly 16 or 18 times as much as the government was investing in medical research. But that, of course, changed through World War II as the benefits of medical research from the war effort became realized in the private sector, and the NIH was launched. That's the story I'm telling. beginning with the Osler textbook leading to the Rockefeller Institute leading to the NIH. I think it's clear to say that very few textbooks survive as long as the Osler textbook of medicine did, which lasted more than three generations and more than 25 editions. I think this new Cambridge textbook of bioethics

Dr. Mark Siegler

will be the first probably of a series of editions. and will be used by clinicians and bioethics students for years to come. And one hopes fervently that Peter's primary goal in organizing and writing that textbook to improve the care of patients will be realized both through the early editions of the textbook and through the later ones. Thank you very much.

Dr. Stephanie Draus

I'm Stephanie Drouse, I'm a naturopathic doctor. I recently joined the faculty of the National University of Health Sciences in Lombard, training naturopaths and chiropractic students, and I would love to have a copy of the book for my classes.

Peter Singer

Fantastic, and there's actually a chapter in there on... Yeah, who's got the one back there? There's yours right behind with that gentleman there. This is fantastic.

Dr. John Lantos

Somebody order some more

Audience member 3

pictures. John, I just want to question sort of your list at the end in particular and thinking about this for you and anyone. It would be interesting to me if you could reflect a little more specifically on the function of genre in thinking about teaching ethics, that a textbook is a particular genre and then at the end you gave this list of other mostly text, but different genres within text, but also suggesting that there are other kinds of media. To think more about the way in which the goals of teaching ethics may be a function of the different genres of the media, of the text, and things other than text that we deploy.

Dr. John Lantos

Thank you. No, I think that's right. I think probably a lot more people learn their bioethics house or ER than they do from all these textbooks combined, whether they're learning good ethics or not.

Audience member 1

So I want to pick up on your discussion, John. My question is, do the panelists think that the reason we have so many different approaches to ethics and so many different paradigms and frameworks and textbooks that don't conform to a single model Is that because of the nature of the problem and will it always be that way or is it just that we haven't sort of come to a common consensus and understanding and someday we might?

Dr. John Lantos

The question is sort of if all these textbooks have a different framework and a different model, is that because the field hasn't matured to the point figured out the right model, or is it because the field itself is so

Dr. John Lantos

variable that we will always have different models?

Dr. John Lantos

Yeah.

Peter Singer

No, I think it's a good question, and Mark, I think, is gonna, and I'd love to respond to

Dr. Mark Siegler

it. No, I agree, it's a very good question. When we did our text, I think we wrote it in 1980 and published it in 82, and actually just finished the seventh edition, went to the publisher on October 1, we had in mind a fairly narrow audience for the clinical ethics book. I mean, we thought primarily of physicians, practicing physicians, maybe hospital ethics committees. I actually did not originally envision that we would reach the medical student audience. Rather taken by surprise that I don't know what, 15 or 20 medical schools have adopted the book as their medical ethics text, which may have been why it stayed through edition to edition. And until John showed his numbers, I always had heard that we were the second best-selling medical ethics text after the Beecham and Childress principles, which clearly was aimed at a totally different audience. I mean, it was aimed at philosophers and theoreticians and undergraduate students doing medical ethics courses, and maybe to a lesser degree, some of the medical school people. But those were targeted in different ways. I'm still not sure that John's data is right, because I think they outsell us. It's on

Dr. John Lantos

Amazon this morning.

Dr. Mark Siegler

My gosh, I'm amazed. It

Dr. John Lantos

may be when you buy books for everybody in the class, too.

Dr. Mark Siegler

The books are on me, I mean, yes. Go

Dr. John Lantos

ahead.

Dr. Mark Siegler

But, you see, I think that the market that you're targeting, the group you're trying to reach, determine in part what the... the book will look like. And it is a new field, and it is sort of feeling its way. And so this Cambridge textbook is aimed at, I think, still a different group from the ones that we were initially thinking about in the 80s.

Audience member 2

I'm interested in getting one of the books. I teach undergraduate nursing students in the clinical setting. And I would like to use it to introduce them to topics that are beyond what they've experienced before.

Peter Singer

Sounds great. Do we have one up there? Do you have any more? We're running low.

Dr. Stephanie Draus

Is there another one? Is there an extra?

Peter Singer

I mean, if you want, send me emails, and I'll send a limited number along, too. There's one here. I've got an extra one. But I'd like to note one deficiency of the book.

Dr. John Lantos

It's around the mailing list.

Peter Singer

There actually is no chapter on nursing ethics and the specialty thing. And I think that's a valid critique. And if there's another edition, we would definitely have a chapter on nursing ethics.

Audience member 4

Let's take one

Peter Singer

more.

Audience member 4

Speaking as a dinosaur who's just finished teaching a class on ethical challenges in medicine to undergraduate freshmen, I would suggest that all of you who write textbooks Google your topic. And if your book doesn't appear on Google, you're not in the running.

Peter Singer

Yeah. And does ours?

Judith Andre

There are ways to make sure that. encountered an old friend over the last weekend who does a lot of websites. He's got 150 websites, something like that. And 110 of them show up on the first page of the Google search for developing keywords. And she got technical

Peter Singer

instruction on how to bring that about.

Dr. John Lantos

OK, want to do some closing comments, panel?

Peter Singer

Peter. I just thought it was a really interesting panel, and I particularly like various different perspectives that people took. I just wanted to thank everybody for their feedback and comments, and thank all of you for your interest. And all I would ask is that you go out and have a look at the various types of textbooks, have a look at this one, because I go back to the fundamental motivation. Believe me, nobody, with the possible exception of Siegler and Beecham and Childress, ever got rich writing a textbook. And I just want to go back to the original motivation, which You know, I think about when I was an intern or a young resident, I go down to the emergency room and I take care of a patient with heart failure, and I've got a good way to do that, you know, in terms of rubrics.

Peter Singer

I think that we still don't have that in bioethics, in clinical ethics, on a topic-by-topic basis, you know, with what's your framework for heart failure, what's your framework for liver disease, what's your framework for end-of-life care. What's your framework for consent? And people who practice bioethics do. That's what ethics consults sometimes are about. But frontline clinicians who aren't bioethics specialists often don't. And it was that set of frameworks really that this was intended to provide with an idea of improving care. So with that in mind, we just urge you and encourage you to have a look. And if you agree with that, and you don't have to, I was just kidding around before, then please do have a look at the book and let others know about it. And as you can see, I'm giving them out for free. The issue here isn't the economics. The issue here is the fundamental goal of trying to do some good in terms of helping clinicians. So thank you. Thank you.

Peter Singer

So let me just briefly tell you about our panelists. First, Giuliano Testa, who is an associate professor of surgery and the director of liver transplantation and hepatobiliary surgery here at the University of Chicago. Dr. Testa specializes in living donor liver transplant, both in adults and pediatric patients. His experience in the field of living donor liver transplantation dates back to 1998, when he helped start the first European