Transcript: Clearly Africa has huge problems. I actually – having traveled there many, many times – think that colonialism clearly has a part. But the fact is the “Big Man Syndrome” isn’t a result of colonialism, the corruption, the suppression of women is not . . . Those are not problems of colonialism. Those are endemic, cultural problems of people, and they need to begin to overcome that. And there are some places which are very helpful. Mali, which is an incredibly poor country – its average per capita income there is under $200 a year – has had a stable transfer of power and government. And you know, that’s a very hopeful sign. Now we have to give them a stable economy and figure out how they can actually develop, and work with them on that. And I think there are other places which can be big successes, but it’s gonna take patience; it’s gonna take investment. It takes a long term strategy. That’s not something the United States is very good at. I mean the long term, we are awful at the long-term.

Recorded on: 7/5/07

Transcript: I also think that we are gonna look back on these years of the Iraq war as a huge national mistake. Now we have had leaders who have brought us into it; but the fact of the matter is that the country ended up endorsing the Iraq invasion. Now it was bad information and all that. But we agreed and we re-elected the president on it. And I think we are going to pay a price for 20, 30, 40 . . . a whole generation. It took us what . . . 40 years to get out of the Vietnam syndrome? It’s gonna take us 40 years to rebuild the military, get out of the Iraq syndrome. And maybe at the end of those 40 years we’ll have won back the world’s good will. A terrible tragedy.

Recorded on: 7/5/07

Transcript: I mean when you look around this world at the number of “failed states” – Somalia, Haiti – you really have . . . Congo . . . you really have to be scared about what that breeds. Pakistan may turn out to be one of those states. Iraq may turn out to be one of those states. And you’ve got to . . . I think we all have to be very worried about that. We have to be religious fundamentalism and the notion of . . . There you really have, I think, something which is . . . is . . . worry about the culture of death. The notion that you go out and kill people and that’s a good thing. Either because you are so alienated from society and you see no future; or because the culture has created the idea that somehow killing people is a way to purity and to being saved. We had a period . . . the war or religions was like that. The Catholics and the Protestants in Europe were killing each other to no end. _______ disappear. Unfortunately we now have that. And we’re not dealing with bows and arrows, but we’re dealing with much more sophisticated weaponry – maybe even weapons of mass destruction. That’s seemingly worrisome to me. I would not be surprised if we ended up with a nuclear explosion, and hundreds of thousands – if not millions – of people – dead. Maybe we would then step – take a step back. But I actually think that’s a real possibility.

Recorded on: 7/5/07

Transcript: Look. You can’t be conscious and not worry about global warming, and about what we’re doing to our planet, and about the use of resources. You also have to be really horrified about our inability in this country to tackle that problem. It’s not a . . . I mean there is a classic case of where we have the technology to solve the problem. We have the insight as to how to marshal that. If we let researchers go wild and support that, we would have a lot more technology. And yet we have not created the infrastructure, or the steady stream of funding, or the political will to actually do that. And that has to sour you on the notion of democracy. That fact that we can’t seem to address a very critical problem where we . . . Again, the issue isn’t so much, “Is this gonna pay off?” It’s gonna pay off hugely. The issue isn’t, “Do we have the technology?” We already have the technology to do this. The problem is we can’t seem to organize it. And that, for me, is a recurring theme in lots of problems. I mentioned it in relationship to the healthcare system. And I think that is something which really does bother me about the United States; that we can see the problems, we can have the ability to solve the problems; and we can’t seem to marshal the forces – social and political forces – to get it right.

Recorded on: 7/5/2007 at The Aspen Ideas Festival

Transcript: I read a recent statistic which just blew my mind away; that today, the average American has 10 times as much material resources as the American . . . that Americans had in the Civil War, which is just a phenomenal thing when you consider it. And it’s all because of technological . . . scientific and technological advances. And the ability to harness energy, the ability to transform energy . . . just phenomenal driver in society. And again, both positive and . . . You know, we have better killing machines too. And so both of those things are, I think, phenomenally important. And you know, we didn’t have much progress in terms of improvement in living standards for millennia until really the developments in the 16th, 17th century of science, and the ability to transform science into technology. And sometimes I think we don’t appreciate the flushed toilet enough. You know, it’s just . . . indoor plumbing, indoor heating. I – in the late 1970s and early 80s – lived in Oxford in rooms that had no central heating. We had a heating coil. And I think you get to appreciate central heating – and the fact that you can actually live at 70 degrees all year around – a lot more when you are freezing and you can’t actually get to sleep because you are shivering so much. And I think that’s just a phenomenal thing to take for granted in our society. And it’s been a very short time since that’s been possible.

Recorded on: 7/5/07

Transcript: Do you leave behind something that’s worth your having consumed all these resources? So I hope that when I die, that I’ll have . . . my kids will be valuable contributors as opposed to delinquents. And I hope that the people I trained, and the books and articles I’ve written, have influenced people for the good.

Recorded on: 7/5/07

Transcript: I’m a practicing atheist, by which I mean I do not believe in God. I don’t understand exactly what that would mean. On the other hand I do go to synagogue evaery week, very religiously, and take that very seriously. And actually, the synagogues that I have gone to over my lifetime have been wonderful, almost all because they have no rabbi. They’re all run by people who are in them. And I have been fortunate enough to go with people who are incredibly smart. The place I go to now is . . . none of them are famous. It’s called an ______ synagogue. They would probably be horrified if any one of them were famous. They are brilliant people. They read the Bible brilliantly. They have brilliant insights into what the Bible means, and it’s very inspiring to do. They’ve actually published a book of various insights that they’ve had called “Leaves from the Garden”, and it’s just an amazing thing.

On the other hand, Judaism is a religion of practice, not a religion of belief. And so even if you’ve lost faith, you’re told you’ve gotta keep up with the practices. So I guess I fall into that category. No faith, but lots of religion.

Recorded on: 7/5/07

Transcript: Oh just hugely! I mean what is a problem? How they address problems; how they can sometimes do tremendous job educating people about the complexities of the problem; how sometimes they can do a terrible job because of the shortness . . . that they don’t allow the complexities and the subtleties to get through. In general actually, I think reporters have really been very interested in trying to understand the details.

I would say that the second problem with the media is the attention span problem. That’s a general problem in our culture. You gotta say it in 250 words or less; but also once you’ve said it, you know . . . How much coverage do we now have today in July 2007 on pandemic flu? The threat hasn’t gone away. If anything, the threat has gotten worse. And yet, you know, you talk to a reporter, “Well we did that last year.” You know? And that, I think, is a terrible problem. Because some of these problems require a long-term focus on an issue. Healthcare reform is another really big issue, which you’re not gonna solve it in a year. You’re not gonna solve it in the next five years. It’s gonna take a long time to focus on the problem; and yet the media doesn’t have that attention span.

Recorded on: 7/4/2007 at The Aspen Ideas Festival

Transcript: Well it’s really looking at ethical issues related to . . . anything related to biomedicine. So as I’ve said, issues like how do you manage with scarce medical resources in the case of pandemic flu? But it also applies to organs for transplant. What are the principles we use to allocate that . . . those scarce items? How do we think about prioritizing? So it’s really thinking about the values that underlie decisions; how you weigh competing values; how do you justify them? That is, how do you give people reasons so that they ought to agree. So one of the things which I like about it is it tends to be somewhat theoretical. You deal with abstract values, but it’s also practical. You have to know what’s going on in the world. You have to know what the real-life problems are. You have to know what are the practical solutions that you can actually implement.

I think one of the big struggles is trying to get complicated issues clear and to . . . both clear in my mind and then clearly expressed and communicated to other people. So let’s take this issue of how to allocate scarce resources like organs, or if we had a pandemic flu vaccine. What are the values at stake? Well one of the things I can tell you a pretty definitive conclusion is there’s not a single value that is gonna determine how you allocate those things. Well one of the challenges is how do you then balance multiple values? And how do you articulate how you’re balancing them and why other people should see it the same way? That is a very challenging thing.

Question: What are the important issues in bioethics today?

Bioethics, I would say there are actually . . . there are problems which need to be addressed, but I also think there’s a sort of manpower problem. We do not have a very good training program in this country for bioethics. We don’t support it actually, despite the fact that it occupies a lot of media attention. Despite the fact that everyone says how important it is, you always hear this phrase: “Our technology is outrunning our values and our bioethical understanding.” And yet we have a very poor way of actually supporting it over the long run so people can take time and address big problems, and think for a while on some of these problems. As I mentioned, some of the issues that we address, we can be sure that it’s gonna take us two years to think through some of this stuff. And we don’t have a mechanism to really support that. And one of the consequences of that is we have not been good at training young people to come through, and to attract some of the smartest young people into the field. And I think that’s a huge, huge issues. Obviously there are lots of particular issues that we need to address better; but I think if we had a lot more smart people in the field with a lot more sustained support, those issues could be well addressed.

Recorded on: 7/5/07

Transcript: A very dominant influence on my life was my maternal grandfather, Herman Small. He was . . . he came here in the early 20th century. Escaped from Russia, actually a smuggled-in illegal immigrant. He worked in the meat packing industry in and around Chicago. He was a union organizer very early on. Built a synagogue. A very big man. Very heavy. Very big hands of a manual laborer. Very committed to trying to make everyone’s life better. We used to spend a lot of days riding in the back of his station wagon as he delivered . . . He eventually got into specialty food stuffs – food imports from Switzerland, and Sweden, and Denmark. And he used to deliver them to specialty food stores way before the sort of gourmet food craze. This was in the 60s. No one had heard of gourmet cheeses. He was doing that. And we used to sit in the back of his car for hours just driving all over Illinois, all over Wisconsin, all over Indiana and talking to him. And he was a very, very caring person. And then for a couple of years he moved into our house. He sold everything. And then at the age of, I think, 72 he was going to immigrate to Israel; but it turned out he was an illegal immigrant in the United States, so he had no passport to leave the country. And he had sold everything, so he moved into our house. And he used to wake up at, you know, 4 o’clock in the morning. And when you got up, he would make you this breakfast that was unbelievable . . . of double-yoked eggs. You could get double-yoked eggs from these specialty farms. And all sorts of . . . fresh squeezed orange juice, all this stuff. And what he did for other people . . . the fact that it was very important for him to care for other people and make sure everyone else was being cared for was very . . . it’s a very, very important thing.

Second important thing was my mother was heavily involved in the Civil Rights Movement in the early 1960s, way before . . . And we were a family that had a lot of black friends. We spent a lot of time on the West side of Chicago with African-American people. And probably one of the most formative experiences there too . . . One my mom – I wouldn’t say every day, but not infrequently – got arrested and would not end up being back home at night. And so that was a very interesting experience. And the other was that we marched . . . When Martin Luther King came to Chicago and marched to Cisaro, we were on that march as kids. And we were pelted with rotten tomatoes and eggs. A very searing experience. You never forget that kind of stuff. And we were able to her Martin Luther King as well in person. And those are, I would say, among the many formative experiences . . . or at least people who were formative to me.

Recorded on: 7/5/07

Question: Collectively, what should we be doing?

Transcript: I think we have . . . Domestically we have to address four problems, and we have to address them relatively soon. We have to address the global warming/energy problem. As I said, I do think we have the technologies. I do think we need to put in the infrastructure incentives just to let our best inventors and our manufacturing go wild. Second we need to reform the tax system to make it more fair, and to bring down income inequality. And I do think that’s gonna be very important for funding initiative. Third we need to change our healthcare system to get a sustainable healthcare system that does guarantee everyone high quality care, and keeps the cost constrained. And the last is we need to invest in education. I think those are our four big domestic issues. And I think they’re all within our grasp, and I think we need to do it for posterity.

Question:What should we be doing globally?

Transcript: As far as the world goes, I think the global warming environment/energy complex of problems needs to be addressed, and I think we can address it. I think we do need to figure out how to bring development to other parts of the world. It’s clear that China and India are developing. They are addressing their poverty problem. They still have many poor people, but they have engines of development and engines of innovation that are gonna solve their problems.

When I traveled to Africa and to parts of Latin America, that is simply not on the mark. They . . . they have political, and domestic, and cultural problems which they themselves need to address; but they also need help in addressing long term, sustainable development issues. We’ve been very bad about that. All the investments at the World Bank have been not great. All of American foreign aid tends to be more for our farmers than for them. We need to integrate them into the world economy. And I think we need to pick out some countries and sort of really show them that it can work, and work hand-in-hand with them about political reform and corruption reform. Clearly Africa has huge problems. I actually – having traveled there many, many times – think that colonialism clearly has a part. But the fact is the “Big Man Syndrome” isn’t a result of colonialism, the corruption, the suppression of women is not . . . Those are not problems of colonialism. Those are endemic, cultural problems of people, and they need to begin to overcome that. And there are some places which are very helpful. Mali, which is an incredibly poor country – its average per capita income there is under $200 a year – has had a stable transfer of power and government. And you know, that’s a very hopeful sign. Now we have to give them a stable economy and figure out how they can actually develop, and work with them on that. And I think there are other places which can be big successes, but it’s gonna take patience; it’s gonna take investment. It takes a long term strategy. That’s not something the United States is very good at. I mean the long term, we are awful at the long-term.

Question: What should we be doing as individuals?

Transcript: Well look. I do not proscribe to everyone, although I easily proscribe . . . I can easily tell you what I think. But I do think we all need to be a little . . . very conscious about our energy consumption. Our family has gone carbon-neutral. It’s _______ very easy to go on the web and become carbon-neutral. We bought a Prius. We’re gonna buy our second Prius as cars. So I think people – especially the upper middle class who can afford it – needs to be much more conscious of its energy consumption. I do think that collectively, we need to figure out what our contribution is to people. I mean this . . . this issue of taking without giving is something that I find very, very bothersome. I mean we . . . you know we live an incredibly good, charmed life. We need to stop being so self-indulgent about it.

I would say five years ago, I was doing some work in Uganda, and I took my kids to Uganda. The family went to Uganda for three weeks. Nothing cures your kids like consumption. And the conspicuous consumption of having the latest “this”, the latest fashion of “that” is going to Africa to see how other people live. And then being a shopper at second-hand clothing stores is grilled into you. Wanting to do good for people around the world is something that is very, very powerfully motivating to youth. I certainly think that something that I see a lot of kids in this generation of college students being very interested globally and wanting to get involved that way. I think it’s gonna be much, much more positively influenced, and much more widely available to kids.

Recorded on: 7/5/07

Question: Whom would you interview, and what would you ask?

Transcript: I’ve actually talked to most of the people that . . . You know, I’ve had the privilege of being able to talk to Bill Clinton. I’ve had the privilege of talking to other politicians. I’ve had the privilege of talking to many great Nobel Prize winning scientists. I actually haven’t found that many barriers to talking to the people I wanna talk to. So I don’t know that there’s one person that would really be burning who I haven’t been able to get to talk to and have a conversation with. So I’ll pass on that question. I don’t know.

Question: What should we be asking ourselves?

Transcript: Oh, I think the question each of us is, “How are we gonna make the world a better place?” When we die, how is the world, in small and big ways . . . You know it could be as local and communal as, you know, I raise great kids. I, you know, led this Boy Scout or Girl Scout troupe. You know, it was very important for these kids’ development to, you know . . . I completely transformed the . . . this part of American society or world society. Or “this” village is better because of . . . I think if we spend time trying to think of how we would write our obituary, and what we would want our obituary to say, the world would be a lot better place. Most of us don’t think our obituary ought to start, “He died with seven billion dollars.” Well if that isn’t the way you want your obituary to start off with, then you ought to think about how you’re making the world better. You know, if you’ve got a lot of either intellectual or financial or other resources, the question is how can you best employ them so that tomorrow, things will be better than they are today?

Recorded on: 7/5/07

Question: When you read the newspaper or watch the news, what issues stand out to you?

Transcript: Well first of all I don’t look at the news. I don’t own a TV, and I haven’t had a TV for almost 30 . . . more than 30 years now. I think that’s actually one of the dreadful things science has given us is television. And I say this as a relative . . . where my relative makes all his money. My brother makes all his money on TV. The big issues that . . . Look. You can’t be conscious and not worry about global warming, and about what we’re doing to our planet, and about the use of resources. You also have to be really horrified about our inability in this country to tackle that problem. It’s not a . . . I mean there is a classic case of where we have the technology to solve the problem. We have the insight as to how to marshal that. If we let researchers go wild and support that, we would have a lot more technology. And yet we have not created the infrastructure, or the steady stream of funding, or the political will to actually do that. And that has to sour you on the notion of democracy. That fact that we can’t seem to address a very critical problem where we . . . Again, the issue isn’t so much, “Is this gonna pay off?” It’s gonna pay off hugely. The issue isn’t, “Do we have the technology?” We already have the technology to do this. The problem is we can’t seem to organize it. And that, for me, is a recurring theme in lots of problems. I mentioned it in relationship to the healthcare system. And I think that is something which really does bother me about the United States; that we can see the problems, we can have the ability to solve the problems; and we can’t seem to marshal the forces – social and political forces – to get it right.

Question:What is the world’s biggest challenge in the coming decade?

Transcript: Well clearly, again, energy use and global warming is one. Wars and the breakdown of political order is another. I mean when you look around this world at the number of “failed states” – Somalia, Haiti – you really have . . . Congo . . . you really have to be scared about what that breeds. Pakistan may turn out to be one of those states. Iraq may turn out to be one of those states. And you’ve got to . . . I think we all have to be very worried about that. We have to be religious fundamentalism and the notion of . . . There you really have, I think, something which is . . . is . . . worry about the culture of death. The notion that you go out and kill people and that’s a good thing. Either because you are so alienated from society and you see no future; or because the culture has created the idea that somehow killing people is a way to purity and to being saved. We had a period . . . the war or religions was like that. The Catholics and the Protestants in Europe were killing each other to no end. _______ disappear. Unfortunately we now have that. And we’re not dealing with bows and arrows, but we’re dealing with much more sophisticated weaponry – maybe even weapons of mass destruction. That’s seemingly worrisome to me. I would not be surprised if we ended up with a nuclear explosion, and hundreds of thousands – if not millions – of people – dead. Maybe we would then step – take a step back. But I actually think that’s a real possibility.

Question:What are the challenges confronting the US?

Transcript: Well we’re . . . we’re in for a perfect storm. Medicare bankrupting the federal government because we have an increasing number of retirees. And not only an increasing number of retirees, but they’re also living longer. I think the average lifespan now, if you get to 65, is 17 and plus more years. That’s gonna be a huge cost on a shrinking number of people who are gonna be able to fund that . . . who are in the working population. So the increase of costs of Medicare, which is gonna dwarf the Social Security problem . . . An increasing number of retirees, and tremendous problems with how to fund that.

Secondly I worry tremendously about the educational system – the primary and secondary school educational system. I don’t think we’re investing enough. And one of the reasons we’re not investing enough because so much money is going to Medicare and Medicaid that we have not been spending enough on primary and secondary education. Educated populous is critical for economic growth. It’s also critical for a functioning democracy. And I think we need a lot more focus on education in this country. Not only primary and secondary school, but even before nursery school and probably early childhood development. That would be a major place of investment in my opinion.

Question: What should be the big issues of the 2008 presidential election?

Transcript: Look. What I think is irrelevant. They are going to be Iraq. They are going to probably be a tax situation because we’re facing a problem in 2010 – a major tax issue. Healthcare is gonna be up there, and probably global warming. Those are probably, in my view, gonna be the big four issues. Whatever I have to say about it is irrelevant.

Recorded on: 7/5/07

Transcript: Both at the same time. I’m optimistic because that’s the only way . . . I mean you can only get up in the morning if you’re an optimist. We believe we can change the world for the positive. That’s what I think. And on the other hand I am pessimistic. I do think we have enormous problems. And I do think there is a kind of sclerosis in the system for not being able to address the system even when we have solutions at hand! And I just find that phenomenally disappointing.

Recorded on: 7/5/07

Transcript: Well clearly religion has – both positive and negative. The wars of religion clearly negative; the idea that you have to have something to believe, something to think about, important.

Obviously technological advances. I read a recent statistic which just blew my mind away; that today, the average American has 10 times as much material resources as the American . . . that Americans had in the Civil War, which is just a phenomenal thing when you consider it. And it’s all because of technological . . . scientific and technological advances. And the ability to harness energy, the ability to transform energy . . . just phenomenal driver in society. And again, both positive and . . . You know, we have better killing machines too. And so both of those things are, I think, phenomenally important. And you know, we didn’t have much progress in terms of improvement in living standards for millennia until really the developments in the 16th, 17th century of science, and the ability to transform science into technology. And sometimes I think we don’t appreciate the flushed toilet enough. You know, it’s just . . . indoor plumbing, indoor heating. I – in the late 1970s and early 80s – lived in Oxford in rooms that had no central heating. We had a heating coil. And I think you get to appreciate central heating – and the fact that you can actually live at 70 degrees all year around – a lot more when you are freezing and you can’t actually get to sleep because you are shivering so much. And I think that’s just a phenomenal thing to take for granted in our society. And it’s been a very short time since that’s been possible.

Recorded on: 7/5/07

Question: Do you have a personal philosophy?

Transcript: Mostly to go around trying to do good things in the world. To try to help people, and to try to do what I can to make sure that the world’s better for my having passed through and consumed all the resources that I have.

Question: Do religion and faith inform your worldview?

Transcript: I’m a practicing atheist, by which I mean I do not believe in God. I don’t understand exactly what that would mean. On the other hand I do go to synagogue every week, very religiously, and take that very seriously. And actually, the synagogues that I have gone to over my lifetime have been wonderful, almost all because they have no rabbi. They’re all run by people who are in them. And I have been fortunate enough to go with people who are incredibly smart. The place I go to now is . . . none of them are famous. It’s called an ______ synagogue. They would probably be horrified if any one of them were famous. They are brilliant people. They read the Bible brilliantly. They have brilliant insights into what the Bible means, and it’s very inspiring to do. They’ve actually published a book of various insights that they’ve had called “Leaves from the Garden”, and it’s just an amazing thing.

On the other hand, Judaism is a religion of practice, not a religion of belief. And so even if you’ve lost faith, you’re told you’ve gotta keep up with the practices. So I guess I fall into that category. No faith, but lots of religion.

Recorded on: 7/5/07

Question: What impact does your work have on the world?

Transcript: Boy. Now you’re asking me to be either modest or an egomaniac. Some of our work has had, I would say, generalized public importance. When I started working on end-of-life care in the 1908s, I was well advised by my professors at Harvard medical school that that was a career-ender. You know? We don’t talk about dying people in medicine. Well that turned out to be untrue, and one of the things I do think I’ve had a small part in contributing to was to try to change the language and the public discussion about end-of-life care. We changed the discussion about living wills and the kinds of living wills we should have. I’ve had a big role – although I don’t know how much of an impact – on thinking about euthanasia and some of the complexities of that. Certainly in the research/ethics area we had a very big impact in setting the framework of how people think about it. Some of our stuff is actually, ironically, being adopted in Nigeria, and Kenya, and Sri Lanka, and other countries as part of their regulation. And we’ll see about healthcare reform. We’re plugging away. We’re working hard. Early days, because I don’t anticipate healthcare reform to be a . . . I mean, we’re gonna have a lot of debates ________; but it’s not gonna be a serious issue until 2013. So there’s a little time.

Question: hat is your proudest achievement?

Transcript: In my career? You’re limiting my . . . I have to be proud of my career, not my . . . my . . . My most proud thing is, of course, my three daughters. That . . . that goes without saying. They’re absolutely unbelievable kids, and I’m very, very proud of them. I’m not sure it’s my achievement, but to be said that I get associated with them, it’s to my benefit.

My proudest achieve . . . I don’t know what my proudest is. One of the things I do like to take pride in is we have trained a number of tremendously talented young people who area gonna be the future of the field. The second is I have a tremendous number of great colleagues. So the department I work in, we have a core group of about 10 people who are just fabulous to work with and are really challenging intellectually. And it’s a . . . I have to get up on Monday morning at 4:00 in the morning to make my plane to go to Washington. And you know, to do that for 10 straight years you have to really enjoy what you’re doing, and you have to enjoy who you’re working with. And that’s fantastic. And the fact that we’ve been able to build this ______ that’s really broken a lot of barriers, and brought new ideas, and really informed how people think about bioethical dilemmas – especially on research – I think is something I’m proud of.

I actually think our healthcare reform plan is . . . There’s no perfect plan, but I think it probably is the best out there. It’s more coherent with American values of equal opportunity and individualism. It’s the most lean in the sense that it has the fewest moving parts. So it’s actually the least corruptible, provides the right incentive . . . I think that’s something I’ll be proud of, I hope, in about five or six years.

Question:What is the biggest challenge your field faces?

Transcript: Well medicine in the United States, I think, faces a real disaster in its delivery system. We know that we’re not delivering care well in that we can’t reliably guarantee Americans will get quality care when they enter the hospital. That in fact it’s almost a 50/50 flip of a coin for people, whether they get the right care or the not right care. That is a disaster. And to change the system to make sure that delivery is better, and that we’re really doing better by people and actually doing it efficiently is a huge challenge at the moment. And I think that, without a doubt, is the biggest challenge facing American medicine. And that’s really gonna, in my view, require comprehensive change of the system. We can’t sort of fix a little here and a little there. I don’t even think getting all Americans ensured is a solution. We actually . . . That’s one small element, but we actually have to control costs. Otherwise in a few years, we’re gonna have uninsured. We also have to improve quality. So that’s a very complicated puzzle. And you just think that American healthcare system costs two trillion dollars – sixteen percent of the GEP – fixing that obviously is a huge, huge challenge. And so I think without a doubt, the medicine, that’s the biggest challenge.

Obviously there are lots of diseases we haven’t solved. Lots of diseases that we don’t even have therapies for. Those are big challenges, but nothing compared to delivering what we know works today efficiently and effectively to all Americans. That is a huge undertaking in management, really.

Bioethics, I would say there are actually . . . there are problems which need to be addressed, but I also think there’s a sort of manpower problem. We do not have a very good training program in this country for bioethics. We don’t support it actually, despite the fact that it occupies a lot of media attention. Despite the fact that everyone says how important it is, you always hear this phrase: “Our technology is outrunning our values and our bioethical understanding.” And yet we have a very poor way of actually supporting it over the long run so people can take time and address big problems, and think for a while on some of these problems. As I mentioned, some of the issues that we address, we can be sure that it’s gonna take us two years to think through some of this stuff. And we don’t have a mechanism to really support that. And one of the consequences of that is we have not been good at training young people to come through, and to attract some of the smartest young people into the field. And I think that’s a huge, huge issues. Obviously there are lots of particular issues that we need to address better; but I think if we had a lot more smart people in the field with a lot more sustained support, those issues could be well addressed.

Recorded on: 7/5/07

Transcript: What inspires me? It’s a good question. I think trying to do good by other people. We have a lot of problems. I have lived an incredibly privileged life. I’ve been fortunate to grow up in America. I’ve been fortunate to get the best that the American educational system has, both in terms of the best primary school, the best high school . . . a fantastic college and a fantastic medical school. And I’ve been fortunate enough to have a pretty good life, you know? The ability to give back and the ability to make a positive, sustained difference to people is what I try to do both in the United States and in other countries where I go.

I don’t think I have a real role model in that sense. There are a number of people – and again I’ve been incredibly fortunate at meeting a number of great people . . . great doctors, great economists, great philosophers, great scientific researchers – who have been just wonderful people. And many things . . . And wonderful people in part because they’ve taken the time to talk to me, and to help me, and to set me right. Is any one of the more inspiring? I don’t think so. But I do . . . I mean when I think of the number – just the sheer number – of brilliant people that I’ve been able to interact with, it’s been phenomenal. And I’ve really . . . Again I can’t say it enough. I’ve been very privileged. When you go to a great college in the United States; when you go to a great university and medical school; when you travel the world, you do meet lots of really smart people and you just wanna learn from them. And I’d also say, you know, there’s a number of high school teachers who were just wonderful, who just taught their heart out. Not just to me but to my classmates. And that, in some ways is, you know, to make you love learning, and to make you wanna learn, and to wanna excel. That’s pretty . . . that gives you lifelong skills.

Well for me since I deal with values, that’s the sort of political philosophy part. I deal with public values . . . values that have to be shared among a very many Americans. And it . . . We try to approach . . . use our understanding of values in relationship to scientific questions. So that’s the relationship. I’m not the only person, but I think there are only two of us in the country who are trained both in political philosophy and in medicine.

Recorded on: 7/5/07

Question: Beyond a simple title, how would you describe what you do for a living?

Transcript: I spend a lot of time thinking, a lot of time writing, and a lot of time talking about important problems in biomedicine. And they can be anything from . . . Early in my career I spent a lot of time worrying about how to improve end-of-life care in this country. I’ve spent the last 10 years trying to think about how to do research studies and experiments better with people, more ethically, more fairly. And in the last probably five to seven years, I’ve spent a lot more attention on healthcare reform and trying to figure out how to reform healthcare systems, and how to improve it because I think it’s in a terrible state. But mostly what I do is any problem related to medicine, or biomedicine, or science that has an ethical component, I get a chance to think about it. And you know, if something crosses my desk that’s interesting . . . One of the things that crossed my desk probably around 18 months ago was how we’re preparing for pandemic flu. And I thought that many of the rationales for the preparation were not very good. And so I decided well, let’s write a paper and think about it and see if we can propose something better. So that created a whole nother project. But it was serendipity. It came out of the blue; but I thought it was a serious public problem but not being well-handled in terms of ethics.

Question: What is the study of bioethics?

Transcript: Well it’s really looking at ethical issues related to . . . anything related to biomedicine. So as I’ve said, issues like how do you manage with scarce medical resources in the case of pandemic flu? But it also applies to organs for transplant. What are the principles we use to allocate that . . . those scarce items? How do we think about prioritizing? So it’s really thinking about the values that underlie decisions; how you weigh competing values; how do you justify them? That is, how do you give people reasons so that they ought to agree. So one of the things which I like about it is it tends to be somewhat theoretical. You deal with abstract values, but it’s also practical. You have to know what’s going on in the world. You have to know what the real-life problems are. You have to know what are the practical solutions that you can actually implement.

Question: What is the joy in what you do?

Transcript: The best thing that I do actually is train the next generation. I have fellows that . . . We have about six new fellows a year. Some of them come right out of college. Some of them already have PhDs, or law degrees or medical degrees. And working with them – because they’re incredibly smart – is one of the great things that I do. That’s one of the pleasures.

Another pleasure is trying to influence public policy, and to sort of try to make a difference in how things are done in the world.

A third thing is, one of the great things about working for the National Institutes of Health is that we have interest and research all over the world; and we’ve been able to go and work in almost all continents – especially in Africa and Latin America and Asia – meeting new people, seeing how their healthcare systems work, seeing their challenges. Having them open up their houses, their hospitals, their clinics to us is a tremendous, tremendous privilege. And it really allows you to understand what’s common among people; and what’s also very culturally different; and I think also where certain practices that we still have might have come from hundreds – if not thousands – of years ago.

Question:What is the struggle in what you do?

Transcript: The struggle? I think one of the big struggles is trying to get complicated issues clear and to . . . both clear in my mind and then clearly expressed and communicated to other people. So let’s take this issue of how to allocate scarce resources like organs, or if we had a pandemic flu vaccine. What are the values at stake? Well one of the things I can tell you a pretty definitive conclusion is there’s not a single value that is gonna determine how you allocate those things. Well one of the challenges is how do you then balance multiple values? And how do you articulate how you’re balancing them and why other people should see it the same way? That is a very challenging thing. We’ve got a paper we’ve been working on for about six or eight months, trying to really work this out. And I can see that we’ll work it out tentatively, but it’s probably gonna be several years of really working on this one problem to really get it. And even then I’m not 100% sure if we’ll get it as clear.

Similarly, I’ve been working for a number of years now on a better plan for universal healthcare reform in the United States. And again, trying to figure out all the parts and how to communicate it to people clearly, and how to address a number of the sort of not very fine details, but other details that really might bore people, but are going to make a huge difference to the success or failure of reform.

And then again to communicate that to people who might not be experts is another big challenge, which I love. I like to talk. I like to lecture. I like to try to make complicated things clear to people.

Question: How does the media affect bioethics?

Transcript: Oh just hugely! I mean what is a problem? How they address problems; how they can sometimes do tremendous job educating people about the complexities of the problem; how sometimes they can do a terrible job because of the shortness . . . that they don’t allow the complexities and the subtleties to get through. In general actually, I think reporters have really been very interested in trying to understand the details.

I would say that the second problem with the media is the attention span problem. That’s a general problem in our culture. You gotta say it in 250 words or less; but also once you’ve said it, you know . . . How much coverage do we now have today in July 2007 on pandemic flu? The threat hasn’t gone away. If anything, the threat has gotten worse. And yet, you know, you talk to a reporter, “Well we did that last year.” You know? And that, I think, is a terrible problem. Because some of these problems require a long-term focus on an issue. Healthcare reform is another really big issue, which you’re not gonna solve it in a year. You’re not gonna solve it in the next five years. It’s gonna take a long time to focus on the problem; and yet the media doesn’t have that attention span.

Recorded on: 7/5/07

Question: Where are you from and how has that shaped you?

Transcript: That’s a very difficult question to ask. I work in Washington and I live in Chicago. Well it did shape me, but not because I . . . We used to go there . . . back there every summer . . .between 1967 and 1970, and literally spend all day out on the beach as three brothers. And so being . . . being there did shape us – actually considerably. And they were very important years between the age of 10 and 13. So I would say that it was . . . it turned out to be a very important shaping experience. And a large part of that shaping was simply being in a country that was . . . had terrorist attacks and struggling but was very vibrant; but also having no agenda and just spending two months at a stretch on the beach playing around . . . playing with your brothers, and talking with your brothers, and doing all sorts of stuff.

Question: ho was your greatest influence when you were young?

Transcript: As a young person? I’d say that prob . . . A very dominant influence on my life was my maternal grandfather, Herman Small. He was . . . he came here in the early 20th century. Escaped from Russia, actually a smuggled-in illegal immigrant. He worked in the meat packing industry in and around Chicago. He was a union organizer very early on. Built a synagogue. A very big man. Very heavy. Very big hands of a manual laborer. Very committed to trying to make everyone’s life better.

We used to spend a lot of days riding in the back of his station wagon as he delivered . . . He eventually got into specialty food stuffs – food imports from Switzerland, and Sweden, and Denmark. And he used to deliver them to specialty food stores way before the sort of gourmet food craze. This was in the 60s. No one had heard of gourmet cheeses. He was doing that. And we used to sit in the back of his car for hours just driving all over Illinois, all over Wisconsin, all over Indiana and talking to him. And he was a very, very caring person. And then for a couple of years he moved into our house. He sold everything. And then at the age of, I think, 72 he was going to immigrate to Israel; but it turned out he was an illegal immigrant in the United States, so he had no passport to leave the country. And he had sold everything, so he moved into our house. And he used to wake up at, you know, 4 o’clock in the morning. And when you got up, he would make you this breakfast that was unbelievable . . . of double-yoked eggs. You could get double-yoked eggs from these specialty farms. And all sorts of . . . fresh squeezed orange juice, all this stuff. And what he did for other people . . . the fact that it was very important for him to care for other people and make sure everyone else was being cared for was very . . . it’s a very, very important thing.

Second important thing was my mother was heavily involved in the Civil Rights Movement in the early 1960s, way before . . . And we were a family that had a lot of black friends. We spent a lot of time on the West side of Chicago with African-American people. And probably one of the most formative experiences there too . . . One my mom – I wouldn’t say every day, but not infrequently – got arrested and would not end up being back home at night. And so that was a very interesting experience. And the other was that we marched . . . When Martin Luther King came to Chicago and marched to Cisaro, we were on that march as kids. And we were pelted with rotten tomatoes and eggs. A very searing experience. You never forget that kind of stuff. And we were able to her Martin Luther King as well in person. And those are, I would say, among the many formative experiences . . . or at least people who were formative to me.

Question: What explains the success of you and your brothers, Rahm and Ari?

Transcript: I love this question because everyone asks things like, “What did your mother feed you?” You know,” What is it about the family?” No one – even though that we’re in the age of molecular biology – says, “Gosh, there must be something in the genetics of that family.” So . . . which I always find interesting being a doctor and a sort of scientist myself why people think it’s environment and not naturally genetics. It’s a really good question. I think that there are lots and lots of things. I think we did have very committed – socially committed – parents, socially committed grandfather. That was one element. Very important. We had a verbal family, you know. If you didn’t talk and if you didn’t get in there with your opinion, you were nobody. We had a very competitive, but loving . . . And this is, I think, is one of those very complicated things to arrange in the family. Anyone who’s been a parent understands. So my brothers and I were very competitive, but we were also loving. For example, as I mentioned, in Israel we spent all summers together. And it was really us three. And so we had to get along, and we had to struggle with each other, and we had to “out prove” each other. And so I think that also creates a bond. I think one of the interesting things that defines all of us is people who work with us and for us are very loyal and feel like we’re very, very committed to them and to their success. And so I think that’s something that we have . . . the sort of very interested in promoting people; very interested in having people work hard, but also recognizing their contribution is very important. And I would . . . I would think that in our family, public affairs was very important. My father was born in Israel. American sports meant zilch to him, absolutely nothing. He never took us to a baseball game, basketball game. We never, I would say, wasted our time in a lot of energy that was directed ________.

I would say the other thing is success is unpredictable in the following sense. I was a very successful student in school . . . the eldest and all that crap that goes along with being the eldest. But my other two brothers were not so successful in school. And it’s not because they aint smart; but they were in my shadow and they needed, you know, their own platform and their own stage. And it really wasn’t until I left college that that became possible.

Recorded on: 7/5/07