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COUNCIL
MEMBERS PRESENT Michael
S. Gazzaniga, Ph.D. Paul
McHugh, M.D.
Welcome and Opening
Remarks CHAIRMAN KASS: Could we get started, please. Greetings, fellow Council Members, Guests, Members of the Public. Welcome to this the 10th Meeting of the President's Council on Bioethics, and welcome to Virginia. I want to acknowledge the presence of our Executive Director, Dean Clancy, who is also the Designated Federal Officer, in whose presence this is an official meeting. In this first session, we will be discussing Pediatric Psychopharmacology, a topic which comes to our attention first in keeping with our exploration of the beyond therapeutic uses of psychotropic drugs in children and in youth, stimulants like Ritalin, anti-depressants like Prozac, of interest to us for their possible uses beyond therapy for personal enhancement and social control. The Council has been on this topic a couple of times in the past. We certainly recognize that there are clear disorders for which these drugs are not just indicated, but indispensable. And yet at the same time, we are concerned about the possible over-use of these medications, and struggling amongst ourselves to figure out what the boundaries are between appropriate and inappropriate use. In the last meeting, a series of possible topics for further exploration was suggested in the Council discussion, some of them financial incentives, practices of insurance companies, and the pharmaceutical companies, but there was also a request that we pursue questions of some of the deeper diagnostic, cultural, and conceptual issues that make performance enhancement and behavior control so tempting, that also might bear upon why depression and self-discontent is so common, and why both are so liable to be addressed through medicines, and through drugs. And to help us in this discussion, we're really very, very fortunate to have as our guest this morning Dr. Steve Hyman. He's a Professor of Neurobiology at the Harvard Medical School, the Provost of Harvard University, and from 1996 to 2001 was the Director of NIMH. Dr. Hyman is a careful and profound student in really all aspects of this topic from the nature of mental illness to the -- its biological substrate and its social and cultural implications, and also on the uses of drugs, the abuses of drugs and addiction. As I learned from conversation with him about a month ago, he began really in philosophy and philosophy of science, and also a kind of a philosophical interest in the matters under discussion. It's really just a great pleasure to welcome you, Dr. Hyman, to the Council Meeting and look forward to your presentation.
tHURSDAY, MARCH 6, 2003Session 1: Pediatric PsychopharmacologyDR. HYMAN: Thank you very much for inviting me. As you and I discussed, we want to have an overview of some very difficult issues, such as how we set diagnostic boundaries in psychiatry in general. There are even more difficulties, as you know, in children where the science is less advanced. I prepared a Power Point presentation. This has become a necessary crutch for all of us for about 30 or 35 minutes. I can't possibly address all of the wide-ranging issues that we need to think about in order to grapple with these topics, but would be happy afterwards as we engage in discussion to go very, very far from what's in the Power Point. Also, I think to be maximally useful, I'm happy to be interrupted during this Power Point discussion if something is opaque, or alternatively if you already have thought about an issue, and feel that time would be better spent elsewhere. I note that I wear my intellectual biases on my sleeve. If you can even judge by the back drop of my title slide, you can see that there's a brain there, so we have a number of different questions when it comes to the use of psychotropic drugs in children. As the absolute medical groundwork, we have to ask whether particular drugs, Methylphenidate, Prozac-like drugs, anti-psychotic drugs are safe and effective. And we have to ask it for different age groups, because brain development means a fortiori that children are not simply small adults. Secondly, we have to worry, effective for what? When we're testing the utility of a drug, are we looking, as we most often do, for diagnosable disorders, or are we thinking as we do increasingly in general medicine about early intervention or even prevention? We have to ask whether we treat risk states for psychiatric disorders in the same way as we do for heart disease. So, for example, I wonder if you had planned to have an ethical panel on the early and widespread use of the statin drugs to lower cholesterol. And if not, I think it's not a question beneath contempt, why we consider drugs to treat the diseases of the mind differently than we treat drugs to prevent general medical disorders. We have to think about unknown, of course it's a great conundrum on how we would learn about long term unwanted drug effects. We'll come back to this. And then we also have to ask a question that is so often forgotten, which is how does an untreated mental disorder, or even - and here I think we get to some of the issues you're grappling with - milder impairment affect the developing brain, and how does it affect real-life outcomes? Unfortunately, we do not have adequate empirical data on almost any of these outstanding questions. There's some things we -- I just would like to assert. I have a few picture slides afterwards, and I don't want to get into scientific detail, but I think it's very important that we not fall into the ordinary trap of thinking that drugs are about the brain, and lived experience is about the mind, and they do not mechanistically interact. In fact, both psychotropic drugs and lived experience affect behavior, both brain, physical substrate and behavior, both short-term and long-term. And both psychotropic drugs and lived experience alter the brain probably by remodeling of synapses, which is something that I know that those of you who are not scientists don't think about every day. This is really just a picture to help me make a few points. This is a picture. It's a drug experiment. It's from Terry Robinson at the University of Michigan, and I just thought it would be worth your seeing physically what I mean by this. On the screen in front of you are two dendrites, the receptive processes of nerve cells, and these are a kind of neuron aptly named medium spiny neurons because they have dendritic spines. And we think that the communicative connections of different neurons make these connections or synapses on these spines. And what you can see is after a certain drug treatment, just comparing the left and the right, that the architecture of these spines is different. Now there's a lot we don't know. Are synaptic connections really made? Is information processing really changed? Is this rat thinking and behaving differently in a way that correlates with these synaptic changes. But I think what's really important to recognize, again just to grapple with this mind/body distinction, is that even beginning 20 years ago, Bill Greenough, a psychologist at the University of Illinois, began comparing rats raised in the normal laboratory shoebox cage with rats raised in what might be called a rat park, you know, with interesting toys and interesting food, not just Purina Rat Chow, but also chocolate chips and so forth. And when he looked at dendritic complexity and cortical thickness, they were really quite different in the rats raised in this enriched versus the shoebox cage environment. The point is that there is no fundamental mechanistic physical difference using drugs to affect the brain and lived experience. In fact, drugs act on mechanisms that are present for normal lived experience in the brain. Now, of course, the potency of the effects and precise effects will vary enormously, but there is no categorical difference. I think that's really quite important to recognize. Now one of the things I understand you're grappling with are the boundaries of psychiatric disorders, so if I can switch from that assertion to the issue of psychiatric diagnosis. This will be fast. I misspelled the title a bit, but -- and we can come back to this. Psychiatric diagnosis today, whether it's for ADHD or depression or anything, is made based on operationalized criteria derived from symptoms and signs. There are no objective laboratory tests for any mental disorders that we normally think about them. There are some appearing, so narcolepsy, which could be considered a mental disorder, has been discovered to be related to defective expression of a particular gene, the orexin gene or its receptor, and there will be tests for this. But in general, we are talking about the scoring of symptoms and signs by human observers. In the DSM-IV, the current American Diagnostic Manual, reliability is king, not validity. Now let me tell you what this is. Reliability is the notion that two independent observers will arrive at the same diagnosis. This is not a trivial feat. Prior to the DSM-III, published in 1978, psychiatry had the Tower of Babel problem- different people could not understand each other. People had idiosyncratic diagnostic criteria. The putative prevalence of schizophrenia in the United States was said to be twice what it was in Great Britain. None of this was credible, and we needed shared diagnostic criteria that would be simple enough, and good enough to permit two observers to arrive at the same diagnosis. This is not the same as validity. This is -- I have another slide later which mentions this, but this is -- validity is about picking out natural kinds, carving nature at the joints, and the two are obviously related to each other but are not the same thing. Now the fact that the DSM has only tenuous claims to validity, although not zero claim, really reflects the early stages of the sciences of brain and behavior. And also, the difficulties of the genetics of behavior. Now at the same time that we have these difficulties, we still have a need to make treatment decisions and to communicate with our patients, so we've come up with what really has to be considered a provisional diagnostic schema. The problem is that that diagnostic schema has become reified in a way that isn't warranted by the science, but is all too predictable. Now I'm just going to show you two pictures again, because to say that the science is difficult and that it's early is just -- it's such an important point to make. And to say that it's difficult and early doesn't mean we won't ultimately understand the biological basis of mental disorders. And again remember, the biological basis means the integration of genetic experience and lived experience, and other environmental factors integrated by the functioning of the brain. So this is a recent paper from Judy Rappaport and colleagues showing over time the loss of gray matter, of cells in the cerebral cortex of children who have an early onset of schizophrenia. And what you can see in these pseudocolor scales -- where always in pseudocolor red is bad -- comparing a normal adolescent with an individual with schizophrenia, that there has been loss of gray matter, and here you can actually, by scanning the same person at intervals, you can look five years later and actually map the loss of gray matter. I'm showing you this because the technology to map, find differences, small differences with reliability in the brain, even to parcelate different brain regions is really a technology of the last years of the 20th Century, and it's still under development. It is not -- when people who are, you know, true enemies of psychiatric diagnosis like Thomas Auz, saidwell, you don't know that the brains are different in his books in the 60s and 70s. He was mistaking the difficulty of the science for impossibility. Now we don't have answers. We can't turn these pictures of regression of gray matter in the cortex of children with schizophrenia into clinical diagnostic criteria. Maybe this will never be a criterion, and if it is, maybe it will take a decade. The point is that we are really at the birth of the kinds of neuroscience technologies, and as you'll see, genetic technologies that can help us get some handle on the underlying biology of mental disorders. Okay. Let's turn to genetics, because this is also very, very important in understanding the boundaries of what are called psychiatric disorders. And here, the glass is both half-empty and half-full. Family studies with appropriate designs, meaning properly designed studies comparing monozygotic and dizygotic twins, that is twins that share 100 percent of their DNA versus twins that share about 50 percent of their DNA. Studies that have been performed of children adopted out of their biological families early in life and so forth do not fully corroborate the current DSM-IV diagnosis, which is to say these diagnoses, based on symptoms and signs, have chosen certain symptoms and signs that experts felt could be reliably scored, and have decided that this cluster equals a disease. We can then go to experiments in nature, to genetics and ask whether the symptom clusters co-segregate; that is, whether they are transmitted as a group, as a single entity from generation to generation. And what we find when we look very carefully is that there are, you know, again not complete invalidation, but not complete validation of the way we do things, that symptoms and signs mix and match in a rather uncomfortably loose way often. Now there's also reassurance. Despite these problems, despite the fact that for, for example, many families with manic depressive illness, you'll find that they have psychotic symptoms, delusions and hallucinations, and the delusions and hallucinations are not passed down exactly together with the mood disorder, for example. Even though we have situations like that, there is reassurance. If our categories were arbitrary, if they were completely fantastical chimeras, we wouldn't see any significant passage of these traits from generation to generation. They would not cohere. And in fact, what family and genetic studies show us, is that the categories we have, as problematic as they are, are picking out something real, so let me make you ersatz geneticists just for a few moments. A useful if imperfect measure of heredity, because it doesn't perfectly separate genes and environment, but it goes something like this. The likelihood of expressing a trait if something is genetic should increase as a person shares a higher percentage of DNA with someone else who expresses that trait. That means that if you share 100 percent of your DNA with somebody and they have schizophrenia, you should have a higher likelihood of having schizophrenia or ADHD, or depression, or diabetes than if you share about 50 percent of DNA with somebody, if they are your dizygotic twin, your sibling, your parent. And there should be correspondingly less association with second degree relatives. And when we, using this crude but useful measure, when we look at what are called recurrence risk ratios, what you can see is, and let me explain this. And I think after this, we're done with the most technical slides, but I do think some detail, rather than bald assertion, is important here. What you're seeing here, this recurrence risk ratio is as follows. Your increased risk of having a, in this case disorder, given that in the first column you have a sibling with a disorder, and then in the second column you have an identical twin with the disorder, where the ratio is your increased risk over the population base rate. And the higher the risk ratio given a, in this case a monozygotic twin or a first degree relative with the disorder, the higher the ratio, the more genetic the disorder. And this kind of information is used by people using the tools of genetics, even to pick what diseases they want to work on. So let's look at schizophrenia. We've been talking about it. The population base rate of schizophrenia is 1 percent. If you have an identical twin with schizophrenia, you have about a 50-fold increased risk over the population, so in this case about a 50 percent, 48 percent risk overall of having schizophrenia. If you have an ordinary sibling, on average you'll share about half of your DNA, you have a 9-fold increased risk. So I want to compare this with Type II or Adult Onset Diabetes, which is widely understood to be a genetic disease, and you can see that genes have a lot more to say about schizophrenia than they do about Type II Diabetes. And even with our problematic classification of ADHD, it has recurrence risk ratios that look very much like Type II Diabetes. So again, these are not ridiculous chimeras, as imperfect as they are. They are picking out something that is transmitted as disease risk across generations. Now some of you who remember genetics would say ah-ha, but those ratios - I should actually go back - like 9 and 48 are not what Gregor Mendel would have taught us; that is, if -- I don't want to get into the details, but rather say this, and we can come back to it in discussion. What the studies tell us overall is that genes play a substantial role in, I've shown you only pathology on these slides, but also in normal behavioral variation. And this entails another whole set of debates, but I would like to forestall them with the second bullet here, which is that behavioral variation, including psychopathology, is genetically complex. That is, when we say in common parlance that something is genetic, what most people have is a deterministic notion that there is a single gene for Attention Deficit Hyperactivity Disorder, or schizophrenia, or Diabetes Mellitus, or criminal tendencies, when in fact, what genetic complexity means is that, as we're going to see, this idea, this simple idea is really of little which is relevant to some rare single gene disorders like Huntington's Disease or Cystic Fibrosis, is of little relevance to behavior, and actually the most common human illnesses. Where it is currently thought that many different genes, many different places in the genome or loci interact to produce risk, and that they interact equally with, or in some ratio with environmental factors, and chance. Chance is often forgotten in this. You can't wire up a hundred trillion synapses in the brain in a mechanistic and reliable way. There are a lot of stochastic effects in this, and that these interactions are non-linear. Genotypes help select the salience of environmental experiences, and those affect gene expression, so these are extremely complex interactions. The other thing which is very important in thinking about disease, something like depression, depression which affects 15 percent of the population, these are not likely to be deleterious mutations in the genome, the truncation of an important protein, something important not being made. Instead, these are more likely to be just variants, that in some combinations are neutral, in others are advantageous, and only in certain infelicitous combinations and in interaction with environmental factors and chance do they produce disease. So let's just think about this again. There's some evolutionary speculation, and it is speculation about, you know, Diabetes Mellitus, that the thrifty genes, the metabolically thrifty genes that would have helped you store fat before the neolithic revolution are not a good thing to have in the era of McDonald's. And these are not harmful mutations, these are just particular variants that are interacting, and give you a particular metabolic situation. And similarly, for behavioral variants, including mental disorders. Now, of course, certain combinations of these variants can give you the risk of very severe illness. I mean, there's no doubt that even if Autism is a group of variants, that depending on which ones you get set you up for being somewhere on a spectrum of being a little bit aloof, which might help you to be a great mathematician, versus somebody who can't communicate at all with other humans, that still doesn't make these things mutations. It means that these -- again, this is an interaction of genetic variants. And let me just say again, we think this is right. I mean, there's a lot of data that this is right, but this is -- we're right here on the edge of genomics and genetics. Okay. Now I just also want to point out for our later discussions, that the boundaries of mental disorders are not the only disorders that are going to be redefined once we understand better the genetics and the genomics. So let me show you a picture of a breast cancer that looked the same to pathologists. So how does one make a diagnosis of a cancer? Well, a tumor is removed by a surgeon, and still today in most cases, a pathologist will put an acidic dye, and a basic dye on the tissue specimen, a 19th Century technology. And the pathologist is very learned in comparing patterns of -- seen under a microscope with certain clinical outcomes. And the pathologist will say this is a certain kind of lymphoma or breast cancer. Well, here is a gene chip, and the investigators here basically arrayed 5,000 different human genes. And they asked whether a gene was on being expressed in a cell, or not on, not being expressed in a cell. And then they asked the computer just to array patterns of gene expression in 98 different breast tumors which are arrayed on the left to see whether there was any pattern of correlation between the likelihood of metastasis. And indeed, with this gene chip you can see that what looked for many years, eons, like one disease, was actually at least two diseases. There are two different patterns of gene expression here shown by red and green. Green is off, red is on, and these are genes that might be very much involved in invasiveness and metastasis and so on, but the point is that genomics and genetics are redefining the boundaries of disease everywhere. The difference between this and behavior, frankly, is again, this is an objective test outside the body; whereas, in behavior, despite the early Judy Rappaport picture of this brain of the young person with schizophrenia that I showed you, we are still lacking any objective tests that we can look at outside of the behaving human being. Well, just to bring this full circle, and to make sure we don't get too focused on the genes, and I've already said this, if genetic complexity were not enough, ultimately it's not our genes but our brain that regulates our behavior. And that while genes are very important, neural circuits are shaped by gene environment interactions over a life time. This is the idea of synaptic remodeling by lived experience. Thus, behavioral traits reflect the interaction of multiple genetic, environmental and stochastic factors. Okay. So it's very complicated, but we shouldn't despair. Our genetic studies to date, for example, show us that we have some coherence. I'm getting pretty close to the end of this. The other thing, and this makes your job harder as you ponder the questions that you are, is that depression, ADHD, autism, and many other conditions appear to be quantitative or dimensional traits. Now the current DSM actually says, you know, to have depression you need to have five out of nine DSM-IV symptoms of depression, and you have to have those symptoms every day for two weeks. Well, that's really quite arbitrary. In fact, of course, the boundaries between -- really getting the boundaries right between normal and diseased phenotypes have enormous impact on treatment decisions. And the truth is that even though these are handled relatively arbitrarily in the DSM-IV, medicine is very comfortable dealing with quantitative traits like hypertension. Basically, how did we decide that 120/80 is terrific, and 140/90 is a disease and warrants treatment? Well, we did long-term follow-up studies, and it turned out that if you had 140/90, there seems to be a bit of a discontinuity, actually, and you have a clear increased risk of strokes and myocardial infarctions. And whereas, the 5 out of 9 DSM-IV criteria for major depression just felt right to a committee, they haven't been exposed to that kind of empirical test, to understand what is a risk state and so forth. The other thing is that we understand that there is early, and transient, and mild, and moderate, and severe hypertension. And again, in the DSM we have no capacity to do that. Okay. Now this is a problem, this issue of not having rational diagnostic thresholds defining either risk states or actual pathology, has -- does a disservice, especially to children. It creates a lot of lack of clarity with respect to when one intervenes in children, both in the over-treatment domain, and in the under-treatment domain. In the DSM approach, you know, you only achieve it if you have 5 of 9 DSM-IV criteria. If that were applied to cardiology, we might limit our diagnoses to angina and heart attacks, and not to early coronary disease or even elevated cholesterol. Okay. The complexity of mental disorders is humbling at the levels of genetics, neurobiology and behavior. But then again, many illnesses in general medicine are not so simple. I showed you a cancer example. It's just true for all common disorders that these are not unitary disorders, but have very complex boundaries. The difference is again, that in general medical disorders there are objective tests that get you within the pathophysiologic family, and we have to live with this. We can't tell people in distress to come back when our science is more advanced. We have to do as well as we can. Okay. So now in the last five minutes, just to give us a -- put this to work, so Attention Deficit Hyperactivity Disorder, you already know this. I assumed you've discussed these things. It's defined as age inappropriate inattention, impulsivity and hyperactivity. It's critical that the diagnosis requires symptoms and disability in multiple settings. Ideally, the workup, therefore, involves looking at the child, interviewing the child, and also the parent and the teacher. If symptoms only occur in Mrs. Smith's classroom but not at home or on the playground, that's not ADHD. It is a clinical diagnosis. There is still no objective test. Even with these diagnostic criteria, when they are well applied by experts with a proper workup, they are associated, it is a high risk state. It is associated with bad outcomes. It's associated with academic and occupational under-achievement compared with abilities otherwise measured. There is an increased risk for substance abuse which, by the way, is decreased with Ritalin treatment, even though Ritalin is abusable. And there is an increased risk for arrest. Anecdotes, you know, one takes with a big grain of salt, but when I was NIMH Director, some of our ADHD research was co-funded by the Justice Department, because there was such an over-representation of kids with untreated ADHD who are incarcerated. It is also associated with an increased risk of other disorders, depression, anxiety and conduct disorder. It's the most common behavioral disturbance that results in a clinical referral. Thirty to 50 percent of kids who are referred clinically for a psychiatric illness have this diagnosis. It has to start before the age of 7. And as you already know, it runs in families and it's likely that some of the risk is genetic. Treatment has been very well studied. Stimulant drugs in particular have been around for a time. We know that behavior therapy is effective. We know that stimulant medication, Methylphenidate is effective. We know that from the very extensive MTA trial which was conducted in 1999 through the NIMH, I have -- it was initiated before I arrived, so I don't have a sense of ownership, that careful use of medication is more effective than behavior therapy. Behavior therapy is interesting. It doesn't generalize across different contexts, so behavior therapy in school doesn't necessarily generalize to home or playground. Behavior therapy in the home doesn't generalize to school. Combining medications and behavior therapy is cost effective only for children, not uncommon, but only for children with co-occurring disorders; that is, ADHD plus anxiety or ADHD plus depression. We also know that community treatment of ADHD is not as good as it should be; that is, there are lots of kids who are on Ritalin but don't have good outcomes, their doses are wrong, they don't know about side effects, they're not being monitored. A certain number of children who are said to have ADHD in our communities and are being treated with stimulants also do not meet criteria for ADHD. Adrian Angold in 2000 had a paper that suggested - he's at Duke - that 50 percent of children carrying this diagnosis wouldn't really meet standardized criteria. There's enormous variability with some communities treating it far less than the epidemiology suggests. The epidemiology again -- so now you know how, you know, problematic these criteria are, but if you apply them, and apply them rigorously, the suggestion is that 3 to 5 percent of boys have ADHD, but we see rates of treatment often close to zero among non-caucasian minorities and some inner cities to the best documented. There was a paper looking at several suburban Virginia counties - it's apt that we're in Virginia - where 20 percent of the boys in some counties were getting Ritalin, and anecdotally in some schools, especially among middle class or upper middle class caucasian males, 30 or 40 percent of the boys may be on Ritalin. That's not rigorous, but even rigorous epidemiology shows this disparity between a 3 to 5 percent incidence, and 20 percent. There is also an unexplained increase in stimulants and other psychotropic drug use. I know that the Julie Zito studies have alarmed many people. I would caution you though, the studies are very difficult to interpret since drug prescription data is divorced from good diagnostic workup, so we just really have no idea what's going on with these kids. The bottom line, there's a mismatch between children in need of treatment and children getting a diagnosis, both under-treatment and over-treatment. We need better diagnostic methods. We need to understand the best use of existing treatment in all age groups, and we need better treatments. I'll skip over where we need to do research. So to conclude, how do we take this -- how do we think about these things? Why did I give you the first 20 or 25 minutes on genes, and brain, and behavior and the complexity of diagnosis? Well, partly we have to remember that while we're worried about the risks of drugs on the brain, you also have to remember that for childhood mental disorders there may also be risks of no treatment. You have to ask how easy is it to recover from persistent problems, in well diagnosed kids with school, and parents, and peers, especially if the symptoms persist. There may be a downward spiral for depression, anxiety, ADHD in which a kid has symptoms, aggregates with deviant peers, gets in trouble with the law and so forth, and these may leave their permanent traces on brain and behavior, and life trajectories. We live in a world of diagnostic gray zones, as Dr. Kass said right at the outset. And increasingly in medicine, we have an ethic of prevention and early intervention. We're told that the time to treat -- that Osteoporosis is actually a pediatric disease that expresses itself in old age, you know, you're building your bone density as a child. Is there a moral difference between lowering cholesterol levels and altering neurotransmitter levels? Why might it be okay for everyone to be on a statin but not an SSRI stimulant or Medaphenil so that we can stay awake and work all night? In treatment there's always a balance between risks and benefits, and the balance is influenced by severity of symptoms and stage of illness. Difficulties related to children with psychological symptoms. For most conditions -- see, if we had this answer it would be easy, but we do not know enough to project trajectories with or without treatment. There is abundant evidence that appropriate treatment decisions, however, are not currently being made with ADHD in particular. We could also talk about depression, because of outside pressures to treat coming from family, school, drug advertising and so forth. Inadequately trained physicians. There are very few child psychiatrists, and pediatric neurologists, and behavioral pediatricians in our communities. Almost all prescribing is done by family physicians who are working in earnest, but don't have the training, and they don't have adequate time or reimbursement for full work-ups and follow-up. A full work-up to demonstrate ADHD would take several hours, or would require talking to several people. And also, medications are seen in many health plans as cheaper and easier than behavioral treatments. And when we go beyond well-defined disorders and high risk states toward early intervention and prevention, the balance of medical risk side effects shifts. Right? It shifts against treatment. There are unknown long term effects of drugs. Now I've talked about unknown effects of going untreated, but now there are unknown long term effects of drugs on a child's symptomatic trajectory. Does giving drugs now mean that a child might need drugs later that they might not otherwise have needed? Well, we don't know. There are symbolic messages to children about self-efficacy. Behavioral control comes from a bottle. We have the problem of anabolic steroids for the soul. Can we really separate health and prevention issues from performance enhancement issues? I think that's a very, very difficult line to draw. And then there's the issue of social coercion or unilateral disarmament. I find it working at the University an anathema that all of our kids, well many of our kids feel the need to get coaching for their SATs, and they get their resumes spruced up, and one couldn't possibly be a serious professional football player, I would imagine, without the use of some performance enhancing drugs. And one might take an ethical position, but taking that position puts one at a competitive disadvantage. And in the case of ADHD in schools, and maybe one day Prozac in the work place, there might be a sense that you'll get the message that to do well, you know, you shouldn't be the only one not being treated. So let me end there. You can see that you have -- well, actually as you know, you've gotten yourself into an area of extraordinary difficulty because of the intrinsic complex nature of psychiatric disorders, because the science of understanding and diagnosis is young, because despite that, we've empirically discovered treatments that have efficacy and a low side-effect burden, because if I'm right and these disorders really are the left-tail of a bell curve and not something discontinuous, these effective treatments will work not only for those severely effected, but those less severely effected, and those who wouldn't even receive a diagnosis. And you're addressing this at a time when we really don't understand fully how sets of behavioral symptoms portend a certain trajectory for children. Thank you. CHAIRMAN KASS: Thank you very much for a very clear, comprehensive presentation. The floor is open for discussion. Elizabeth Blackburn. PROF. BLACKBURN: With relation to your table with the risk ratios, you gave some very precise numbers, and then you talked about the degrees and the quantitative aspects of diagnoses. And I was curious about those numbers, did they come from the extreme very, you know, say 9 out of 9 symptoms for depression, for example, category? DR. HYMAN: Yes. PROF. BLACKBURN: Because I could see -- DR. HYMAN: What we did basically, and it's interesting. The genesis of this slide was when I was NIMH Director, and we were about to make an enormous investment in genetics, we were working out -- that is, which diseases warranted an early attack on the genetics given the complexity as genomic approaches were maturing. And it was quite clear that autism, schizophrenia, and manic depressive illness, because of their very high risk recurrence ratios, were apt targets for genetic studies, and actually other things were a lower priority. And the way we went about it is basically to do a search and find every credible well-designed, adequate end study that had been done comparing identical twins, dizygotic twins and siblings. Per force they were done in different countries using different diagnostic criteria, and if we did this in a more technical meeting and you saw error bars, you would be somewhat alarmed, but in the end, I think there's a general consensus that these numbers are not far off, representing the heritabilities. PROF. BLACKBURN: Yes. No, I take the point about the relative contributions of heritability, but I was curious, for example, bipolar, you know, 7-fold for sibs, 60-fold risk ratio for monozygotics. But then if depression, which is only part -- DR. HYMAN: Yeah. PROF. BLACKBURN: I mean bipolar is only part of that, 15 percent so clearly there must have been a subset -- DR. HYMAN: Oh, bipolar -- PROF. BLACKBURN: -- how broadly you define these things. DR. HYMAN: I'm sorry. Okay. So depression, when we -- so if you've ever had a manic episode you're not in the unipolar depression category, you're in the bipolar category. PROF. BLACKBURN: Yes, but from what you're saying, since you took studies from multiple countries -- DR. HYMAN: Yes. PROF. BLACKBURN: -- it must have been a fairly broad set of criteria that were included then in these things. DR. HYMAN: Yes. PROF. BLACKBURN: I was curious about whether this represented, you know, as you say, the right hand side of the bell curve for these diseases. DR. HYMAN: Right. PROF. BLACKBURN: It sounds from what you're saying as though it's a fairly broad set of definitions. DR. HYMAN: Yeah. I would have to -- I mean, for autism it's not so broad. For major depression, it is broad. We were dependent on the world's existing literature, but I take your -- your point is -- if your point is that the input data has certain infirmities, it certainly does. PROF. BLACKBURN: No, I wasn't -- DR. HYMAN: Yeah. PROF. BLACKBURN: I think the point is well-taken, and I certainly think there's every reason to think this. But I was just curious about how broadly some of these things were defined. Were they looking at the extreme ones where you could be very, very clear. DR. HYMAN: I think, yes. PROF. BLACKBURN: Or did they segue into them -- DR. HYMAN: So for autism, bipolar disorder and schizophrenia, they're very, very clear. I think for major depression there is no clarity. PROF. BLACKBURN: Okay. Thank you very much. CHAIRMAN KASS: Rebecca Dresser. PROF. DRESSER: You were very balanced and fair in your presentation, and I wondered if I could get you to express a point of view on something that's relevant, not just to this project on "Beyond Therapy", but also another project we have, which is regulation. You seem to say that in some situations that diagnostic criteria are fairly defensible, but there's still this problem of getting professionals to apply them stringently, or even with reasonable rigor. And also, dealing with parental demand, I suppose sometimes patient demand. I wondered if you had any ideas on what might be done to address that problem? DR. HYMAN: I have no problem expressing a direct opinion on this topic. I think that in medicine in general, in psychiatry in particular, and in pediatric mental disorders most particularly, there is -- as early as our criteria are, if they were well-used, and if children were followed-up appropriately to ensure that the first diagnostic hypotheses and treatment suggestions were optimal, it would be a much better world. I think the data suggests, as my slide listed, that most prescriptions, as far as we can tell, for psychotropic drugs are made by family physicians, well-meaning to be sure. I do not want to bash family physicians. They are working at an extreme disadvantage. They have been untrained. They have no time. I mean, it's fine for me to say that you should spend several hours on a diagnosis, and one of the things you want to do is make sure not only that the child is in trouble in the classroom with the teacher, but also is being rejected by peers on the playground, so it's fine for me to say that. The family physician is not trained to know what questions to ask, very often has 11 minutes to get from the beginning of the intervention to writing a scrip, and would not be reimbursed to take the time after the visit to make those phone calls. As a result, and in combination with outside pressures that exist in certain school systems, and through advertising, I think that what we -- there is a yawning gap between what we know, which is imperfect but good enough in a rough-and-ready way and what we do. I would also say that while I focused on diagnosis, I think the follow-up issues are as or more problematic; that is, if the medicine isn't working and has side effects, it may or may not be stopped. Kids who really need it may not be complying, and nobody notices, so I think there is an enormous problem of medical practice. Let me say one other thing about coercion, and let me give you a thought experiment, because I think it's -- coercion already carries with it negative connotations, you know, the evil empire forcing a child to take the medication. We can certainly imagine a situation. Why you don't risk a unilateral disarmament situation, where you have a few symptoms, and you're not performing so well, and all of your friends are taking this drug, and their parents and the teachers are happy consumers. That's not an ideal situation. I don't think anyone could defend that. On the other hand, there's a case where there's 25 kids in a classroom or 28, and one teacher, and there are two kids who have symptoms of severe behavioral disorder, who absorb almost all of the teacher's time. And any of you who have children or have been in a classroom know that this is a reality, and so the 23 kids don't really get much of an education. Now the issue here is that schools should never be making diagnoses, and schools should never be saying, as has been rumored, you know, get Johnny on Ritalin. That's absolutely wrong. But for schools to demand that somebody be worked-up or treated in a certain way so that everybody could learn I think is a different issue. And I think when we think about the roles of schools, you have to think not only about the dark 1984ish scenario, but also about the second scenario, and weigh those. CHAIRMAN KASS: Do you want to follow-up, please? PROF. DRESSER: This is rather provocative. I was involved in a group of pediatricians addressing the growth hormone question, and one idea which didn't really go very far was that only pediatric endocrinologists should be able to prescribe because of this desire to do a good work-up, and keep the boundaries. Has anybody ever proposed something like that in this area? DR. HYMAN: It is absolutely infeasible. The number of -- I mean, in most -- if you think of inner cities or most of rural America, the number of trained pediatric psychopharmacologists, behavioral neurologists, or behavioral pediatricians tend towards zero, and so the burden of doing this correctly must be on the family physician. The pediatric growth hormone issue is, as you know, exactly analysis. Short stature, but my child does have short stature. He was going to be a center for an NBA team, you know, and I'm drawing that line. CHAIRMAN KASS: If I -- Rebecca when she first started to ask about the -- whether you had some suggestions, in fact, about the regulation of this practice, you've gone and indicated why it is in need of such attention, but in effect said this is a problem for professional practice. And almost all of the pressures make it almost impossible for it be done. Is that the best that we can do? DR. HYMAN: I hope not. On the other hand, regulation that flies in the face of reality is -- decreases respect for regulation and fails. CHAIRMAN KASS: Of course. DR. HYMAN: You know, I would -- I have long believed -- so I've told you I believe that family doctors are going to carry the burden of most of this. I think certainly that at least in certification requirements, there has to be increased attention among family physicians to pediatric psychopharmacology. I mean, if you look at the numbers of young people receiving Ritalin or an SSRI, this must make up a very substantial part of general pediatric and family physicians practice, and I think some kind of training is necessary. I must say in my years of looking at the gap, as I call it, between what we know and what we do, and physician behavior, I've become not quite despondent about the power of education by itself, and I think that some kind of accountability to make sure that these -- that what is being taught is being practiced in some way is very, very important. But that accountability, if it just accrues to the physician who doesn't have time or resources, and is not reimbursed, becomes very, very problematic, so I think it has to be -- it really has to look at health systems in some sense, and really look at the quality of the overall work-ups that are being performed and reimbursed within a system. CHAIRMAN KASS: Dan Foster. DR. FOSTER: You used the term that on a "rough-and-ready" basis if the things that we know were followed, we would be in a much better world, the sense being that although there might not be a bright line between disease and -- DR. HYMAN: There isn't. DR. FOSTER: There isn't and so it's broad. DR. HYMAN: There is not, yes. DR. FOSTER: At least there would be some broad category of defense about prevention and so forth. And you talked earlier a little bit about a curve that went on into normality, where there might still be an enhancement from excitatory drugs and so forth. I just wondered if you -- I think I know what you would say about this, but merging out of the issue of children with - as an example here - what is your opinion about the enhancement virtues that kids in college and so forth, you know, are using these drugs extensively and so forth? Is that defensible or not defensible in your view? DR. HYMAN: I really struggle enormously with this. It really comes down -- I'm not going to give you a crisp answer because I'm not done struggling. It comes down to the anabolic steroids issue in some sense. Athletics has decided that you are supposed to -- I mean, even though we know that illicit and problematic use of drugs continues in sports at all levels, tragically sometimes leading to death, the sports community will assert that it wants human beings to compete with each other in athletics, only based on their bodies and the physical training that they undergo. And that the use of drugs is just not to be part of an athletic contest. And in some sense, if you -- that idea, which is so -- always breached, or often breached, that idea which is so attractive, really doesn't translate very easily to life as it is truly lived. And here my impulses, my libertarian impulses, and impulses as a physician begin to take over. If somebody feels distressed and doesn't meet any criteria, and finally a physician says well, I don't really know what's going on with you, but let's try this thing. It's marketed as an anti-depressant, but since everything is really probably on a bell curve, you know, it doesn't stop working if you don't have 5 out of 9 DSM-IV symptoms. And the person has no side effects, or model tolerable side effects, and really it relieves their distress, and they're a better husband or wife, and they're functioning better at work. It seems very difficult in America to say that they can't feel better. I think it's actually impossible to say that. But then that scenario shades into the dystopic notion that but if everybody in the work place is -- if these drugs get better and better, and everybody in the work place is on these drugs, might we not have a coercive situation where somebody who wanted to engage life without a psychopharmacologic agent is now being in some sense forced to join the crowd, which is the situation if you want to an interior lineman in the NFL. You might have moral questions about anabolic steroids, but you would be ill-advised if that's your chosen career to avoid them, so I can't give you a crisp answer. I think it's really -- if you think about the case, the first case I gave you -- I mean, I've given you extreme cases, but in the first case it would be very hard to say that somebody couldn't have the drug, and in the second case one begins to really imagine some fairly nightmarish scenarios. And I think finding -- if there is some way of finding an appropriate middle ground, I imagine that's what you are all engaged in, and I can't make it easy. You might think my interim solution while I struggle is not strong enough, but my interim solution is really that physicians, because these are prescription drugs, physicians really have to be a lot better. They can't say -- somebody can't say I've read an ad for -- you know, I've been shy all my life, and I read an ad on a side of a bus, and I want you to prescribe X. I mean, the physician really has to understand the person's symptoms, and treat a prescription as an empirical trial, and not a birthright, and stop it if it's not working, and weigh risks and benefits. And maybe it doesn't make you happy as an answer, but we're not even there, we're not nearly there. CHAIRMAN KASS: Could I pursue this with you unless, Dan, you want to follow-up? Are you okay? Yeah. In the presentation, on the one hand at the very beginning, you make clear your view that both lived experience and drugs affect the brain. DR. HYMAN: That's correct. CHAIRMAN KASS: And that there is no fundamental categorical difference. DR. HYMAN: At the level of the brain. CHAIRMAN KASS: At the level of the brain. DR. HYMAN: Right. CHAIRMAN KASS: Yet toward the end when you talked about the kinds of problems that might -- and among the list of problems about the use of these drugs was the concern that you would be sending symbolic messages about self-efficacy to children. DR. HYMAN: Uh-huh. CHAIRMAN KASS: That somehow drugs were a better way to deal with their difficulties. DR. HYMAN: Uh-huh. CHAIRMAN KASS: And then this question about the anabolic steroids for the soul which we talked about. DR. HYMAN: Right. CHAIRMAN KASS: If you bracket the question of social coercion that might come if you were dealing with competitive situations, and simply talked about the fact that look, we don't know whether there's a diagnosis here. In fact, it's not clear this is a medical condition, but there's some kind of self-discontent. And you've already pointed out that in the absence of certain kinds of treatment, the possible plasticity of the brain might, in fact, be under-developed and not used. CHAIRMAN KASS: Why wouldn't you say that -- why don't these concerns sort of vanish, concerns at the end if you begin to think about the thought at the beginning; namely, that we could use pharmacological agents to help lots of people feel somehow better about themselves, in the wake of which feeling better, all kinds of other experiences might go better. The brain might, in fact, develop and become richer. Isn't this just sort of priggish concerns that you have? DR. HYMAN: Yes. No, no. No, no. Well, I think that's why I began with athletics, where society has made a decision that you're supposed to be competing naked of pharmacology. And we haven't made that decision when it comes to the rest of life. WE're uneasy. I mean, we are generally uneasy. And the whole reason I struggle is because I can't refute that final position that you took. Let me also say at the beginning, there are also certain kinds of experience that can have bad effects on life trajectory presumably mediated by the brain, by long-term changes in the brain. I mean, we're worried about pathologic gambling, you know. That's a lived experience. That's not a pharmacologic experience, and it can have very profound effect on brain function. I was really just making the point that we can't -- you shouldn't rest your deliberations on the idea that there's something fundamentally categorically different between drugs and experience and their effect on the organism. There are other issues that we are struggling with, which has to do with symbolism, with relative moral weights, and of course, with medical side effects, risks and benefits. CHAIRMAN KASS: But bracket the side effects. DR. HYMAN: Yes. Right. CHAIRMAN KASS: Why isn't, in a way, the philosophical teaching about the brain sort of at odds with the desire to privilege the symbolic meaning of do it for yourself without drugs? DR. HYMAN: Yes. CHAIRMAN KASS: Bracketing your -- no one is going to ban anything here. DR. HYMAN: Right. CHAIRMAN KASS: Bracket libertarian concerns. DR. HYMAN: Right. CHAIRMAN KASS: And just talk about the kind of anthropological question, moral self-understanding. DR. HYMAN: Well, I think that there is a symbolic difference that we don't -- that we often don't recognize that plays itself out, often in irrational ways in other aspects of medical practice. For example, we are quite well aware that most people will not control their cholesterol with diet and exercise over the long run. And yet, every medical textbook tells you to start with diet and exercise, and force somebody to fail through this exercise in self-control before you would prescribe a statin, even though the statins are, you know, they're -- we can bracket side effects, but they have side effects. And I think what we'r talking about here is what kind of society -- I think what we're engaged in is what kind of society we want to have, and whether we, as a society, want to recognize as valid, unstigmatized, and in no way diminishing of someone's humanity, that they gain appropriate treatment even early, or preventive treatment for identifiable high risk states, but that in general as a society, we would like people to work with their own native abilities, with their own struggles. The alternative view is that if we can find medications which will enhance our performance, lengthen our life, decrease the stress, do we really think that Aldous Huxley was right and we'll end up, you know, in some "Brave New World", or is it more likely that we will end up in a happier, healthier world where people can all function well? And I think we don't know the answer to that, and what you and -- what we are all here together struggling with is we're worrying about the Huxley and dystopic, but it would be hard to say that we should not be aiming for the more utopian version of this. And in fact, if such drugs were to be developed, no regulation in the world would keep them from general use. CHAIRMAN KASS: Michael Sandel. PROF. SANDEL: I'd like to continue along Leon's lines. What he's been doing has been -- you gave us a very balanced and elegant, and terrifically, for me, informative overview of these issues, and you have an instinct that's emerged in the discussion for which you call the appropriate middle ground, but Leon, and now I am trying to drag you into the fray that we've been occupying. DR. HYMAN: Uh-huh. PROF. SANDEL: Which is partly an ethical and ideological fray, as it intersects with the medical and scientific account that you've given. DR. HYMAN: Absolutely right. I mean, medical practices -- there are a lot of problems in medical practice that have to be addressed, but we're talking about something very separate from medical practice now. PROF. SANDEL: Right. DR. HYMAN: So you're not letting me hide. Yes. PROF. SANDEL: Okay. So if I could continue along these lines. First, when you gave your general, your opening account of the mind, calling into question the sharp metaphysical mind/body distinction, both drugs and experience have effects on the brain, to some ears, to some people listening to this, see that finding, if it's true, as threatening to something they believe about ethics and about freedom, and about moral responsibility. I don't think that they're correct in seeing this as a threat -- DR. HYMAN: Correct. PROF. SANDEL: -- to proper understandings of freedom and moral responsibility, but there's a powerful philosophical tradition that supports their worry that this would be a threat. DR. HYMAN: Right. I agree. PROF. SANDEL: But in any case, to come closer to the surface of these ethical and ideological issues, so you signalled -- those were fighting words your account, your brief account about drugs and experience having effects on the brain. And then you reinforced them, and you posed as a question if statin, why not stimulants? DR. HYMAN: Right. PROF. SANDEL: What's in principle the difference between the use of the two for prevention and early intervention?Maybe we stigmatize the second more than the first, but is that defensible in the light of this earlier thing, so that gets closer. And then -- so to take one step further along the lines of Leon's questions, go back to the sports case. Now you dodged that by saying well, we as a society have decided that we want sports athletes to play just with their bodies and physical training. DR. HYMAN: Right, but you could imagine a different -- PROF. SANDEL: Well, first of all, it's not clear that that's true sociologically, and even if it were, it might be mistaken. DR. HYMAN: Right. Right. PROF. SANDEL: And one could raise questions about improved running shoes, or graphite tennis racquets and so on, which have nothing to do with bodies or with physical training, but which are external in just the way that drugs would be external. DR. HYMAN: Uh-huh. PROF. SANDEL: You don't object to that, so at the level of sociology, it's not so clear that we've accepted that. In the Sports Illustrated expose of the use of steroids that they pointed out that players now speak to each other in the language of "playing naked", you're not going to play naked, are you? DR. HYMAN: Yes. That was my unilateral disarmament. PROF. SANDEL: Right. DR. HYMAN: Right. PROF. SANDEL: But here's the issue. Suppose we put aside questions of safety, we find something that doesn't have bad side effects as steroids do. DR. HYMAN: Uh-huh. PROF. SANDEL: And we put aside the question of fairness, that by making it available to everyone if they want to, to use it let's say in sports, some drug that will enhance performance, that doesn't pose medical risk, and that's equally available on a voluntary basis to anyone who wants to use it, so you remove the fairness. Now you may say well, there's some people who want to be play naked, they'll be effectively coerced, but if it's safe, then it's no more coercion in that direction than it would be in the other direction if you said people who want to use it, can't use it. DR. HYMAN: Right. PROF. SANDEL: So it would be a draw. So the coercion is gone, the fairness is gone, the safety objection is gone -- something objectionable about enhancing performance through a drug rather than through, let's say, a more rigorous training or better genetic luck. That's question one. The second question is the parallel to that in the case of Ritalin, in the case of stimulants. And here, there's been a lot of discussion about over-treatment, and over-treatment reflecting an ideology of the, you know, the diagnostic manual, this ideological -- DR. HYMAN: Right. PROF. SANDEL: It's led, or permitted and over-treatment. DR. HYMAN: And there's also under-treatment. PROF. SANDEL: Well, but you -- DR. HYMAN: As are more problems -- PROF. SANDEL: Well, that's a different emphasis you brought from the ones we've had in previous discussions. You said well, we have to look at the risks of not treating, we have to look at the incidence of under-treatment. And if it's safe, and let's say even hypothetically to isolate the issue, if it doesn't have adverse health side effects, then the under-treatment would be worse than the over-treatment. DR. HYMAN: Uh-huh. PROF. SANDEL: So the question then, the first question is this -- the hypothetical in the sports case, and the analogy in the Ritalin case. If we do away hypothetically with the medical risk, is there anything objectionable to letting any kid whose parents let's say agree to have Ritalin to improve behavior or concentration on the SAT, provided it's available to everyone, and assuming for the sake of argument it weren't risky. DR. HYMAN: So you'll force me to take off my medical hat that makes me worry, and to address in very naked terms where I would come down. I would say that if there were drugs that could enhance performance, that were perfectly safe, but I want to define safe on my terms. The key for me is, and this is very unlike the soma of "Brave New World", there must be no clouding of consciousness, there must be no alteration of -- no artificial control of overall moods, but rather -- in short, we don't want people getting high all the time. I would include that in a risk. It's very important for me to segregate, you know, artificial elevation of moods and change in human judgments into the category of side effects. But if we had drugs that were free of that, I would think that it would be -- they would be acceptable. I think that -- DR. GAZZANIGA: We do. That's Ritalin. DR. HYMAN: Well, not quite Ritalin. I mean, Ritalin is not -- well, let me come back to the second point. The reason that you've found me so worried about this in talking about the moral symbolism is I also believe that it is better for humans -- we never want somebody to have to struggle against difficulties with some rectifiable disorder, defect or disability. We want to bring everybody up to a certain normal level of function, with the understanding that that's a very gray zone. But it's also important -- I would argue that a society which -- if a society errs in the direction of increased personal responsibility and sense of moral agency, that's a better society than a society which errs in the opposite direction. And that while I said yes ultimately to your first question, the way you set it up, the way that such drugs would be used, the way Ritalin can be used, worries me because of the risk of undercutting a broad societal sense of moral agency and responsibility. I don't think that -- and the two positions are not really fully congruent. Right? Because I know that one of the risks of having risk-free performance enhancers is potentially to undercut a set of moral agency and responsibility. And yet, it is very hard for me to find a bright line where if these things were truly risk-free, didn't make people -- give people artificial emotions and impair their human judgments, that I could say that we can't have. We will have. What I'm saying is we have to learn to manage them, and we have to learn to manage them in a way that minimizes the loss of a sense of moral agency. DR. FOSTER: I just want to interrupt for a second to say, I'm not sure at all about the issue of safety of Ritalin in young children. I mean, I'm not sure that it's a safe drug anywhere, but particularly I don't think that the neurological circuits and everything are completely, you know, at 7 years of age you're not worried about that. You remember that -- if you look at something like alcohol and pregnancy, I mean four hours of alcohol at 200 milligrams percent you've got a defective brain. DR. HYMAN: You know, Dr. Foster, I don't want to cut you off, but time -- I'm going to have to go exactly at 10:30. DR. FOSTER: All right. DR. HYMAN: Let me just say, if you actually look at the data, imperfect as it is in any clinical trial, the data would tell you that properly used by any criteria that we have, Ritalin is a safe drug. Can it be misused? Yes. Can it be abused? Yes. Do all drugs we have today have side effects? Yes. But compared with almost actually another drug we have that we use in psychopharmacology, oddly the data that we have suggests that Ritalin is the safest. Now you and I might argue about this, but I don't think that's where these questions are going. CHAIRMAN KASS: I have Gil, Paul, Bill. You have how much time? DR. HYMAN: I have to leave at 10:30, about five minutes. CHAIRMAN KASS: Okay. Well, let's try to -- briefly then. PROF. MEILAENDER: Yeah. I'm confused. If I follow what you said to Leon, and then to Michael, it would seem that you're not prepared to draw a line against enhancing performance for perfectly normal people. DR. HYMAN: Right. PROF. MEILAENDER: Enhancing performance so long as it doesn't have bad side effects, one of which would be altering of moods. DR. HYMAN: Artificial elevation. PROF. MEILAENDER: Yes. So somehow a person who just, you know, is not clinically depressed or anything, but just goes through life a little discontented and would like to be happier, has less claim to be helped than someone who without help can get a 1400 SAT and would really like to hit 1550. If I'm understanding your right, I just don't see why anybody would draw that line. DR. HYMAN: Would draw the line. PROF. MEILAENDER: Yes. Why do you have more sympathy for the person who wants to notch up the SAT than the person who would like to be a little happier. DR. HYMAN: I'm sorry. I don't have more sympathy. I just -- PROF. MEILAENDER: Well, you're more prepared to permit them to look with some -- DR. HYMAN: I must not have expressed myself -- well, I just said I have much more sympathy with the sickest person, and -- PROF. MEILAENDER: I'm not talking about a sick person, just a person who'd like to be a little happier. DR. HYMAN: What I'm saying is, I don't find a rational way to draw the line to say that at some point we can't -- I've been trying to take refuge in good medical practice, and I've been not allowed to do that, and ask whether in principle I would draw a line in which somebody with no diagnosable illness - right - with no diagnosable illness would not be allowed to take a medication. And what I'm saying is that if you ask me naked of all my protections about medical practice, follow-up, and this and that, I would have to say I can't find that line right now, but that I'm worried about the impact of that on the sense of moral agency and personal responsibility. CHAIRMAN KASS: Paul. DR. McHUGH: I'm sorry you have to leave, Steve, because we could go on for a long time talking about your presentation, and how thorough it was. But I want to come, if you would, just briefly to talk about the foundations of your opinions here today as expressed. I know you have other opinions, and they turn on this idea that we're dealing with reality out there, and we have to make accounts of reality. But, Steve, you know perfectly well that those realities of our making, particularly from the psychiatric side. And that DSM-III-R, IV, and IV-TR are based on a particular approach to things that had a reason 25 years ago, to try to get us to talk, but now has its own deep problems, very deep problems. DR. HYMAN: Right. DR. McHUGH: Including the expansion of psychiatric disorder so that it's now a huge, huge thing. DR. HYMAN: Right. DR. McHUGH: The belief in appropriate treatments now being offered for various forms of conditions that are placed in there, certain forms of PTSD, social phobia, multiple personality disorder, and all of that rests upon this idea that a top-down approach of checking off a checklist is the right way to diagnosis. With your hope that ultimately we'll find a validation of that from -- DR. HYMAN: A different set of -- DR. McHUGH: Yeah, entirely different. Now since that reality is of our making, that's what makes for the 11 minutes is all you, and that you can't teach people appropriate approaches to psychiatry, I have two questions. What are we going to do about getting a psychiatric approach to diagnosis that approximates medicine? DSM-IV does not approximate anything like medicine in ICD-9 and 10, as you know that, so that's the first question. And the second question is, do we understand development, maturation and acculturation for it's psychosocial tasks adequately, and its responsibilities for the development of the child right now to be able -- for most children to be able to intervene with medications? You said that drugs and life experience do the same thing to the brain. And you know I agree with that. They certainly change the synapses. But we also know that both drugs and live experiences can do terrible things in the process of building -- DR. HYMAN: Right. DR. McHUGH: So question one, where are you going with DSM-IV to DSM-V? Secondly, do we understand anything to be able to satisfy the gentlemen on this side, and ladies on this side, to say that we know how to build a child sufficiently well to make the gains on your SAT scores adequate to the things you lose in depriving them of the opportunity to play more, to have different friends. DR. HYMAN: Right. Okay. So this is -- right, these were not exactly yes or no questions. DR. McHUGH: No. DR. HYMAN: You know because you've read my criticisms of current psychiatric diagnostic nomenclature, that I find enormous problems, and again, in one minute, we have a difference between trying to coalesce around and name important conditions that we really see that people have, like manic depressive illness or schizophrenia, versus the exigencies of a profession that wants to be reimbursed for its work and is forced by, you know, the reimbursement system to give a lot of things names, and we know that there is a lot of -- this is not theoretically neutral or apolitical, but at the same time, I have a certain amount of sympathy in my better moments given the -- the real difficulties of doing better given the state of our science, so we have to change, but I don't have any easy prescription for how to change. And I'm very conservative about blowing up an existing system. I'd like to fight its excesses. You and I would both like to fights its excesses, but I don't want to blow it up until I have something really that -- until our genetics is farther along, our neuro imaging is farther along, because we'll go back to Babel. The other issue is exactly my problem, and Professor Sandel here smoked me out, that I am living -- on the one hand I can't find, you know, a bright line that if we really had perfect drugs which didn't create, you know, the 1980 -- I'm sorry, the "Brave New World" scenario. I could find a bright line to outlaw them, but at the same time, my -- as I said my precise concern is the messages that we deliver in terms of human self-efficacy and moral responsibility. And if you can find a way to manage the reality that will dawn on us, there is just no doubt that minimizes the undercutting of a sense of human agency and moral responsibility, without unfairly stigmatizing those who are truly in need of treatment. You have my blessing and best wishes. Unfortunately, I have to be off -- DR. McHUGH: If I could just reply to that just to say that maybe the thing that we need is not more neuroscience at some level and better psychiatry at some level, both to develop a classification and to answer some of these questions about what maturation itself is doing to individuals, and that's where my problem. CHAIRMAN KASS: Dr. Hyman has to return to teach a class. It's heroic of him to have come on a teaching day to spend time with us. Thank you enormously for a wonderful session. We're adjourned for 15 minutes.
(The session then went off the record for a break.) *** CHAIRMAN KASS: This is a session on the topic of "Beyond Therapy: Ageless Bodies?" Before we start into that, at least a couple of the people who had their hands up when time ran out have spoken to me about a possibility of at least putting into the record certain kinds of questions or concern, not so much to interrogate Dr. Hyman, who unfortunately had to leave, but if people would briefly like to simply put into the discussion the questions or concerns that they had, since that was a conversation that was just about to take off, I think it would be appropriate if we allowed room for that. I had on my list Bill May, and Bill Hurlbut, and I don't know if there was anyone else in the queue. Bill, do you want to add something? DR. MAY: Well, I felt that Dr. Hyman talked about the gap between what we know and what we do, which tends to lead to too much over-treatment, and too much under-treatment. But earlier he really talked about the gap in science really, it's a young science we're talking about. And also, there's a second gap between what we know now, and what we would like to know to feel comfortable about what we do. And both of those gaps seems to lead in the direction of saying no regulations, no bans, but it makes you very dependent upon a guardian class in the interval before you narrow the gap between what we know now, and what we should know to feel fully confident in what we do. But what was quite depressing, it seemed to me, is you depend upon the guardian class, but it turns out that our guardian class doesn't have the timing, or the time or the training to do what it ought to do in order to guard. So no regulations given the gaps with which we live, real dependency upon the clinicians, but we discover the clinicians are woefully under-trained in operating in a system where they have no time, even if they had the training, to do what needs to be done. Which again leads bioethics out in the direction of systems, institutions and structures, away from some of the issues that we've dealt with. CHAIRMAN KASS: Bill Hurlbut. DR. HURLBUT: I was going to inquire of Dr. Hyman whether he thinks that he would see ADHD in a hunter/gatherer community, and in the same amount. And whether it really is in some way an artifact of narrowing our definition of normal, because it seems to me that -- well, if it were a Mendelian trait, we'd define polymorphism as 1 percent of the population. Here we have 3 to 5 percent. It seems like well, 3 to 5 percent of the population could have some kind of a deficit, but then the question becomes well, is this just part of the spectrum of human variation in a positive aspect of our society which should not necessarily be treated or narrowed, but given a different educational process and opportunity to develop in its own trajectory. I think it's interesting that ADHD is kind of a derivative diagnosis based on the educational system. Isn't that where it's first picked up, as inability to sit at a little desk, read little black symbols off of white pages, and not playing out with the activity that normally accompanies childhood for most of human history? What worries me about this is it also goes deeper than that. I think the idea that this is a genetic disease, which is -- certainly, there's a strong corollary between monozygotic twins, but that doesn't necessarily mean it's even genetic, of course, because it's -- they share nine months in the womb. And there are some people that believe that maternal stress during gestation provokes this problem, and that even if it were correlated through generations doesn't prove its genetic because there are now evidences that stress itself is echoed generation after generation. And what worries me in that is that when you label something genetic, it's much easier to justify the concept that it has a single unitive source as maybe a missing enzyme or something like that, and then justify a medical diagnosis and a pharmacologic intervention, so I think those are worth saying. And then just two final points. One is that I disagree with the statement that was made, if I understood it right, that there was no difference between treating somebody who seems to fall below the norm and somebody above. I think there's an intrinsic difference there, and one case you might argue that it is more like therapy in the sense that it's normalizing, that it's bringing somebody into community. On the other hand, that's when you treat the left side of the bell curve. But when you treat the right side of the bell curve, it's intrinsically competitive because it's moving you away from the norm into a realm of superior performance. I mean, there's a lot more to be said about that, but I think if you think of human community as the ground not just of human strength in sociology, but also human meaning, then there's an intrinsic difference between the treatment of those two sides of the bell curve. And finally, it seems to me that one of the fundamental dangers in this simplistic notion of a genetic deficit is that the reification of a very complex human phenomenon where we tend to think of complicated human realities as treatable by some kind of magic bullet, when in fact the closer you get to meaningful human existence, the less easy it will be to intervene, because human beings have evolved, or have been created, however you want to see it, to be distanced from determinism, and even simple molecular interventions. The most meaningful human existence is somehow the comprehensive willed self-governance of our humanizing activities. And to the degree that we give over easily to notions that there are simple deficit disorders, we have to be very cautious about that because that's a very dangerous assumption in a complicated species like our's. That's not to say I don't believe there are disorders like that, and I'm not saying this one isn't, but it just strikes me as a very, very important point. And actually, let me add one final point to that. Even if you say this is directly related to say a genetic cause, there are historical conditions that suggest that we need to be very, very careful about what we think that cause is. An example of that would be cleft palate and the relationship with mental retardation, which was long assumed to be correlated. And then when it got to the point where our medical treatments could go in and do surgical interventions early enough, we realized that that so-called genetic mental retardation was actually a byproduct of the fact that the cleft palate was blocking the eustachian tubes, causing earaches and otitis media, and muffling speech, and therefore, causing the children to not be able to keep up with their peers because they couldn't hear and understand what was going on. So what looked like a genetic cause of mental retardation, turned out to be just a secondary. CHAIRMAN KASS: Okay. I think there are people who are also in the midst of developing their own thoughts in relation to Dr. Hyman's presentation. And Paul and others, if you'd be so inclined, a couple of paragraphs leading to some kind of question, we would welcome them at the office, and we can send them on to him and see if we can elicit from him some further elaboration on some of the things of concern to us. Let me turn to -- DR. FOSTER: Leon, let -- could I just -- CHAIRMAN KASS: Please, Dan. DR. FOSTER: I want to sort of give a reference for the library that people might have here, because one of the things we talked about in the last hour was the issue, the moral issue of one struggling without the help of drugs and so forth in mental illness, and maybe some of you have seen it, but Leon Rosenberg, who happens to be a close friend of mine, Leon Rosenberg has published his experience with manic depressive illness. Leon was a Dean at Yale Medical School for 10 years, and now works at Princeton, and Robby probably knows him in molecular biology and so forth. He published an article called "Brainsick", and it's in Cerebrum, Vol. IV. I can't remember the pages, last year. It's one of the most remarkable documents that I have ever read, a confession about a struggle from youth, ending up finally in a suicide attempt in which ultimately then somebody who struggled against this for life, was a great investigator, became the Dean of Yale, and all these things, trying to fight this alone, and eventually succumbed and surrendered to a suicide, requiring ultimately electroconvulsive therapy and Lithium and so forth. It also is a familial, as he outlines, it's a familial illness, and it simply emphasizes to me the difference between a highly moral struggle to try to do it by one's own in an illness which ultimately requires medical therapy. And so it's heroic in one sense, and in another sense it's a tragedy. I mean, not that he didn't achieve everything, but he might have had a happier life if he could have done that. So I simply wanted, if you haven't seen it. It's a rather obscure journal, and so -- but I thought it would be an interesting article to put into the archives of the library that the Council is putting together. CHAIRMAN KASS: Yeah. Thank you, Dan. We'll find it and actually circulate it to members. DR. FOSTER: Yeah. Leon Rosenberg is the author.
It's called "Brainsick" in Cerebrum. Okay.
Session
2: Beyond Therapy: Ageless Bodies CHAIRMAN KASS: Thank you very much. Other comments before we move forward? Okay. The topic of this session is "Beyond Therapy: Ageless Bodies?". This is a piece of the "Beyond Therapy" project in which we are investigating those uses of biotechnology to intervene in the human body, in the mind, affecting the life span and the mode of generating new life. We are working toward writing this up, and I hope by the next meeting, before the next meeting, there will be things to read of a more coherent and unified sort. In the previous sessions when we touched these topics, we had invited outside experts to tell us where the science is, both now and prospectively. What we have in two sessions today is a return to these topics to look at the human and moral significance of acquiring these new powers, in this case, over the aging process. And the next case, over some aspect of human memory. And this is a much more difficult task, where we're engaged in forecasting the human significance of things which are not yet here, and in which the meaning of any one of these developments will be connected with many other things that may or may not happen, either in biology, or in society, or what have you. And part of the reason for tackling this project is to allow at least one aspect of that cumulative meaning to come forward; namely, what human life might look like if a variety of these powers arrived at once, or arrived in concert. In this session, we've put together reflections on what it would mean to intervene either in toto in the process of the human species, or in part, looking at the possibility of stronger and longer-lasting skeletal muscles through the intervention of various biotechnologies, in particular, genetic modification of muscles. You'll recall that we heard about this from Dr. Sweeney already last, I want to say July. The Staff has prepared two papers which are in the briefing books. I trust you've read them. In this session, rather than go in the usual form, sort of episodic comments, I would see if I could try to hold the reins a little more tightly and discuss some of the, what I think might be the critical issues. Let's stipulate that these techniques would be widely available, relatively inexpensive, and for the sake of the discussion, relatively safe. And that one would either be able to significantly extend the human life span through intervention in the aging process, or more modestly, that one would be able significantly to affect human musculature through interventions. And let's also, I think probably not as reasonably assume that these things would be equally available, so that we don't raise, at least for the moment, the question of unequal access, or the fact that these would be the gifts only to the rich or to the privileged, just so that we could look for the moment at the thing itself. And I guess the two staff papers have, in addition to reviewing the state of the science, listed a number of possible implications of this, both for individuals and for the society as a whole. But I thought I'd like to begin and see if we could discuss the question. Does it strike us as reasonable to regard biological aging on the model of a disease which would be at least addressed, if not remedied or alleviated, at least to some extent by medical intervention? The conceptual question now of how we sort of think about the process of aging, whether this is rightly to be thought of as on the model of disease begging for medical examination, intervention, and possible remedy? By the way, I should mention while you're pondering, and I'm going to stop in a second, the latest issues of Science magazine, 28 February, has "The Research on Aging: The End of the Beginning" is the theme of the issue, and it's linked to a website, "Science of Aging Knowledge Environment", SAGE KE, which has a whole series of articles which describes this really as the end of the beginning phase of this research. And in fact, talks about the conclusion of the editorial, quotes Charlie Chaplin, "That we are all amateurs. We don't live long enough to become anything else." It goes on to say, "If the aging process could be attenuated, humans would have additional healthy years to bring their personal goals to fruition. The challenge to society will be to ensure that those goals are compatible with the needs of humanity", whatever those might be. It seems that we -- our discussion has at least got the imprimatur of the latest issue of Science Magazine, so we're not too far ahead of the curve. Let's start with this question. Is it reasonable to think that the biological processes of aging are rightly regarded as analogous to a model of disease to be studied and modified? Elizabeth. PROF. BLACKBURN: I think the problem I'm having in reading the paper which didn't clarify it, and I think we should bring up now is, we're going to assume mortality at some point. Right? We're going to assume that that will happen. And I think the issue is the rate at which we approach that from some peak state. Right? And so, if we -- none of these discussions seemed to deal with the idea that we could imagine a scenario in which we had different kinetics of the various stages in life, and so you used in the paper the rubber band analogy where everything is stretched out. And I'd like to return to this, but the quick question is, if we assume that these sorts of ideas are based upon the idea of an extension of the say prime years of life as defined by, you know, whatever your prime favorite decade is, your 20s, or 30, or 40s, whatever, 50s, but then -- and then 60, of course, terrific decade. And then there would be a decline that would be say, to put it scientifically, a particular slope down to death. Right. Now you keep that slope the same, but now that slope would only begin at say 100 years old. Right? What you've done is simply extended the adult phase. Right. That would be saying that there is a phase which for the life, contour and so forth is, you know, a decline which everybody would have, but the delay before its onset would be different, and that's what I'm not clear about. You see what I'm saying? Or you could have mortality in two seconds, you know. Suddenly, you're going from prime to death, and I don't know if that's the thing that's being specifically discussed here, that there is no intervening period of what one has been calling senescence. Could you clarify, because I could see various trajectories. If you'll line them up, there's three. The rubber band, everything is equally stretched. Twenty-four months of gestation, three decades of teenagerhood. Great. I can see that's not going to work. Right? So let's say -- and I think developmentally that is incorrect, so I think we probably will mature at reasonable ages. Then the question is -- at reasonable speeds. Then we get to adulthood. Should there be an adulthood of 80 years of undeclined abilities and so forth. Right. And then a normal rate of decline, i.e., we decline at some normal rate as a species, and then there's mortality. Or the other extreme is that you have the extended decades of adulthood, and then a very rapid decline, because we're going to assume that there's death at the end. CHAIRMAN KASS: Right. PROF. BLACKBURN: Right. And it seems to me that is the part that is troubling these discussions, that there is not a normal rate of decline at some potentially delayed point in life. CHAIRMAN KASS: Yeah, I suppose, and I should be corrected on this, but I suppose it's not possible to know in advance of more work on the science and more work on what the particular interventions might produce as to which of those latter two models one is likely to be going for. PROF. BLACKBURN: I think it would be helpful if we -- CHAIRMAN KASS: So could we extrapolate -- PROF. BLACKBURN: I think we should discuss each one separately because they raise very different issues. There's the rapid decline issue. Right. CHAIRMAN KASS: Right. PROF. BLACKBURN: The preparedness for ultimate mortality which I think is, you know, the question being raised, but that may not be -- you know, that's one issue. And then another issue is what about the idea of having say, you know, 70 years of full prime adulthood. And I think that's another thing. And for the discussion, I was going to propose that maybe we separate them, because I think that would be helpful. As I was reading the paper, the very well prepared paper, I saw a certain sort of mixing in of many of those arguments. CHAIRMAN KASS: Okay. Charles. DR. KRAUTHAMMER: Could we not extrapolate from our experience in the last century where there was a dramatic increase in life expectancy, and I guess we might conclude from that that the opening trajectory, the early years are the same except for infant mortality, of course. And then you end up with extended adulthood, and probably a decline that would parallel -- I suspect senescence today is not that different from 500 years ago, except it's perhaps extended because of the -- we probably have longer periods of decline and illness than happened a millennium ago. PROF. BLACKBURN: Right. When infectious diseases would perhaps claim -- DR. KRAUTHAMMER: Right. So if anything, you'd have a slightly flatter curve at the end, rather than a steeper one. PROF. BLACKBURN: Yes. So I think you're saying we're already very experienced, you know, as a society in much of this. DR. KRAUTHAMMER: Yes. PROF. BLACKBURN: We've already done a lot of this already. DR. KRAUTHAMMER: Right. So I'm just saying in speculating about an answer to your question, I would say let's look at what happened when we've already had some life extension. I would suspect the trajectory at the end would be probably the same slope, and perhaps a little shallower. CHAIRMAN KASS: I'm not sure one could know, because the changes over the last century are none of them due to interventions and the basic process of aging. I mean, they're all either reductions of infant mortality or just reductions in specific lethal diseases, and much wouldn't you think on how the basic process of aging is in fact interfered with as to what the pattern would be. And we could pick and choose if one wants, and have a discussion stipulating one particular pattern. The other thing is it's true that we've had some experience with social changes over the last century that have changed the age demographics of the population, and you could either argue that on the one hand that's a laboratory for study, or you could argue that in some ways it's irrelevant because we haven't really touched the maximum. In other words, there are very few people living a lot longer than anybody ever lived before, and so the question of whether a five generational world or a six generational world can be somehow fully understood in terms of the changes that have taken place, where more and more people go to live to their three score and ten or four score. So I mean we have some things to go on that would help us think about this. We're not absolutely in the dark, though it's a long question, I think, whether the precedent is simply adequate. Let's see if we can specify the conditions of the discussion and then address the question. You know, my experience always is you ask a question of a bunch of professors and they're going to change the question on you, except for you, Charles. Shall we, for the sake of the discussion, say let's conceive something that would treat -- that would interfere with aging so as to simply expand a stretch of the good years, however you define them, without affecting terribly much the period of character of the decline, and let that be the basis of the discussion. And ask the question, is it reasonable to somehow think about the processes of aging that prevent us from going from instead of 20 to 65, going from 20 to 105 before entering into sans teeth, et cetera. Robby. PROF. GEORGE: Sorry not to address the question. CHAIRMAN KASS: I expect it. PROF. GEORGE: But just for clarification, when you use the term "aging" in setting the question, you said the biological processes of aging, so -- CHAIRMAN KASS: As discussed in -- PROF. GEORGE: In the paper, right. So I'm wondering about the distinction between the biological processes of aging and disease in order to evaluate whether we can conceive the biological processes of aging on a par with disease. What I have in mind is a sort of -- can be expressed in a kind of simple flat-footed way. WE go to grandma's house for Thanksgiving. She greets us at the door. How are you, grandma? Oh, I'm okay. What do you mean you're okay? Something is wrong? Oh, nothing. It's just old age. Right. Now when she's saying that, she's referring to some biological processes, but she probably has various things, various symptoms that are diseases, aren't they? Or things are breaking down, things aren't going right. It could be anything. It could be Gout, it could be -- well, all the things that happen to us as we get older. Now is there some distinction between the biological processes of aging and just that collection of things that grandma has in mind? PROF. SANDEL: Well, does anybody ever really die of old age? PROF. BLACKBURN: I think they do. I think there's a very real -- if we take, you know, reduce it to the humble nematode worm, you know, referred to by Steve Austad in a session where he presented, it's very clear that you see these worms that have absolutely everything supplied to them, and yet they will have a trajectory of decline which you can, as we heard, alter by very simple, sometimes single nucleotide changes in their genomes. And there's a clear process. Right. Now we don't like it and so we call it disease, but I think it's a very real process, and can be quite distinguished. And the fact that it manifests itself in a series of definable symptoms and definable tissue states, I think doesn't -- changes the real biology. I think that's what's being learned, that there is something real there. Now your question is, can you treat each of these tissue issues as a disease and treat them all, and that's, I think, a good question. PROF. GEORGE: Have we exhausted it? I mean, at that point, have we exhausted everything there is that counts as old age? I mean, I think we probably in every case if grandma listed them, we'd say oh, yeah, we want the doctor to take care of that. Yeah, we want you to go to the doctor for that. Don't sit around. Yeah, we want you to go to the doctor and have him take care of that, but then after we've exhausted all that would we then say but look, there's no point in going to the doctor just to fight old age. PROF. SANDEL: Could I just follow up on that? This is a dumb question but I think it's a really good one, and I don't know the answer. Most of the -- you talked about worms where we can see this, but most of the people I know who die of old age, almost all of them had something wrong with them. PROF. BLACKBURN: Was that because their intrinsic ability to fight off the disease, or their ability to control a particular tissue growth pattern? You know, in other words, something -- PROF. SANDEL: I don't know. I'm asking you what's the answer? PROF. BLACKBURN: I actually don't know whether -- Dan, you must know. I don't know. DR. FOSTER: Well, I think that Mike is right, that most of the time, you know, if you do an autopsy, we don't do too many autopsies any more, that there's almost always an association of some illness there from which they died. But from time to time, not too infrequently, a person dies and there's no cause of -- part of the difficulty is that most people who die a normal death at home don't get autopsied, so they may -- you know, there may be something. I think I mentioned once before, if you have a perfectly matched kidney, for example, that it lasts about -- and you transplant it, I mean a transplanted kidney perfectly matched, after about 30 or 32 years, it begins to fail. And when you biopsy it, there's no rejection by the body, there's no disease in it.It just appears that entropy has finally triumphed, and so we're getting ready to transplant, somebody has just done that. And Tom Starzl who started off the whole transplant thing, said they just die of old age. I mean, that's a phrase, you know, the kidney just dies of old age, so I don't know the answer to the question. It's complicated, because if you're in a hospital where most of the deaths, then you say yeah, this person died of cancer or coronary artery disease, but I don't know about the grandmother who dies at home peacefully in the sleep. I mean most people would say well, they had a run ventricular tachycardia or something and died quietly, so I don't know the answer to it for sure. DR. KRAUTHAMMER: I'd suggest that anybody who dies happy is somebody who died of old age. All the rest died of something else. DR. HURLBUT: Dan, do you mean that if you transplant a kidney from an older person, that that kidney is going to die in the life span of the older person, not in the younger recipient? DR. FOSTER: No. I don't even know what the, you know, most transplanted organs are from young people, you know, who -- unless using a living donor who -- so the kidneys are usually not from older people, so it's just -- you know, I'm talking mystically here. DR. HURLBUT: Well, say a parent to a child, to their child. DR. FOSTER: Well, I can't answer that question. You mean, would that kidney live longer, you mean, if it was genetically -- DR. HURLBUT: Would the kidney senesce along with the parent's life trajectory, or would the -- DR. FOSTER: Oh, yeah. I don't know the answer to that. That's not what I understood Starzl to say, that it was the life expectancy in the recipient, unrelated to the donor is what I understood him to say, but I don't know the answer to your question for sure. CHAIRMAN KASS: I'm going to -- DR. KRAUTHAMMER: Could I try to answer, Leon? CHAIRMAN KASS: Are you going to answer the question? DR. KRAUTHAMMER: Yeah. CHAIRMAN KASS: I want to read something. I want to read the -- look through the paper and then I'll let you -- just so we've got it. DR. KRAUTHAMMER: Sure. CHAIRMAN KASS: And this is the notion that the senescence researchers use. "Aging synonymously used in this paper with senescence denotes the gradual progressive loss of function over time, beginning in adulthood, leading to decreasing health and well-being, increasing vulnerability to diseases and increased likelihood of death", that there is some process of decline of function, gradual loss of function over time which at least the aging researchers distinguish from the particular diseases that go by. PROF. SANDEL: Could I ask you about that? That means that when -- to go back to the thing that Gil is always taxing me with. When I get less and less good at playing baseball, as I approach my 50s, what makes that happen is the same thing, the same process as what will kill me if I don't die of a disease, even though my lessened ability to play baseball isn't itself a disease. Is that what you're saying? CHAIRMAN KASS: Let's leave aside the question of whether anybody actually dies of old age. That seems to be a sidepoint. That there is some kind of process of gradual loss of function that is separate from specific diseases, everybody in this room ought to be able to give personal testimony to, that there is this kind of underlying process which wears us down. And the question is, should we come to regard that like a disease against which we should bring the powers of medicine to bear. Charles, are you going to take that one on or not? DR. KRAUTHAMMER: Well, I would just offer, to be as provocative as I can in answer and to provoke discussion from that, would be that disease implies some defect in biology, some error, some deviation from the normal trajectory. It was hard to see how philosophically you could call aging a disease if it is the 100 percent norm for all organisms, so from that perspective, a biological perspective, I would say that I find it hard to call it a disease, it being such an intrinsically natural, if you like, process. From the human psychological perspective, it's a disease in the sense that it creates problems which we want to fix, and that -- and we regard -- it sort of ranks psychologically as a disease in that sense, but I'm not so sure how much applying the word helps us in deciding what to do about it, but that's what I would offer as an answer to is it a disease? Biologically, philosophically, no. Psychologically, it feels like it; therefore, we treat it as one. CHAIRMAN KASS: Paul. DR. McHUGH: I want to continue to follow-up on this, and Michael's point. First of all, on the baseball story, we do know exactly how the aging process affects the batting averages of major league baseball players, and there was a wonderful article written demonstrating the difference in the batting average trajectory of decline in the ordinary 35, 36 year old baseball player and Lou Gehrig. And you could see how the onset of the disease, Amyotrophic Lateral Sclerosis, cut short and altered what was an already declining skill. I think the important point to note is that as we understand diseases better and better biologically, we stop talking about them as entities, and begin to talk about them as life under altered circumstances of some event, some genetic event, some invasive event, some neoplastic event, or something of that sort, and we attack those particular events as altered life circumstances available to us. As we do that, let us say with a disorder like Huntington's Disease, where we see -- or Alzheimer's Disease, the accumulation of particular proteins and particular losses of things. We are going to chip away at what is happening ordinarily in a slower form. We're going to find the cure for Alzheimer's. We're going to find a way to -- let's not necessarily cure it, postpone Alzheimer's Disease, Huntington's Disease, and in that process you're going to see the little things that accumulate in aging, and which represent a combination of several processes, some of which give us particular vulnerabilities. So my answer to the question is that I think we're going to redefine disease, and explain disease in ways that also ultimately explain aspects of senescence. CHAIRMAN KASS: Elizabeth, and then Gil. PROF. BLACKBURN: But that suggests -- again we have two issues on the table. One is, the postponement of this, should we postpone it but say inevitably it's going to happen at some rate that's normal. And I think Paul, and perhaps Charles are raising the possibility that once, you know -- there's a second thing. As each thing goes on, should it be treated individually, and make that curve more and more shallow? I see them as really two distinct kinds of issues, not only as issues, but also underlying basis for them. One is the postponement and one is the treat everything as it comes and make the curve shallower and shallower. CHAIRMAN KASS: Gil and then Michael. PROF. MEILAENDER: When you asked your original question, I thought I understood the question clearly, just wasn't sure what the answer was. I'm increasingly unclear about the question, and here's -- I think I can say why anyway. If you say should we regard -- is it reasonable to regard biological aging as disease?I mean, the reason we want to talk about that is to know whether -- I mean, presumably if it is, then nobody would object to trying to stop it, at least retard it, and slow it down, postpone it. But now the image isn't clear to me any longer. I mean, we have Elizabeth's several images, but if we're thinking about a period of time in which I'm -- what you call the good years. I'm if not at the very peak of my powers, at least really doing well. And then we think that at some point decline begins, and we want to know if somehow it's reasonable to think that we should think that something analogous to disease has happened when decline begins. I mean, I'm certainly not there yet, you know, but eventually we all get there. That's one question, but actually your definition suggests that I'm aging all along the way. And even while I'm at the peak of my powers, whenever exactly that was, it is no longer, I'm aging. If that's the case, then stretching it out doesn't seem to be postponing it at all. It stretches out the period of time over which it happens, but aging is happening all along, so you're not stopping aging from happening. So I don't think we're really -- I'm not sure we're talking about stopping aging as happening, or whether what we're really talking about is some moment in the lifelong process of aging when decline becomes pronounced, and we want to intervene. But there's a sense in which on the definition, you know, the 30 year old at the peak of his powers is aging, and I don't see that stretching out the period of time in which he feels that way is stopping aging in any technical sense, so I -- you know, it's confusing to me. The fact that this time in which precipitous decline has not happened is longer, is not retarding aging. DR. MAY: (Off mic.) PROF. MEILAENDER: Sure, I suppose that's right, but it's not retarding aging. Aging is happening the whole time, whether I age over 70 years or 100 years. PROF. BLACKBURN: You're slowing the physical properties down. You're aging in the sense you're accumulating experience throughout those -- let's say there's a period of comparative youthful physically adulthood. Right. You'll be accumulating mental experience in that time period, so you'll age in that sense chronologically, but by the -- you know, again the simple model systems where they look at the worms extending their life span six-fold, they really have a postponement for all the obvious physical onset of things, and then those take place with a fairly normal trajectory. PROF. MEILAENDER: But that is not a postponement of aging. PROF. BLACKBURN: It is a postponement of all the symptoms, physical symptoms of aging. PROF. MEILAENDER: Physical symptoms of what? They have -- as I understand the definition, they have been aging this entire time, whether you stretched it over a longer period of time or not. PROF. BLACKBURN: Well, no, they didn't stay very youthful. That's the difference. CHAIRMAN KASS: Let's take the -- here's the example from the muscle would be a useful particular in which you could see it. In those muscle experiments that Dr. Sweeney reported on, the injection of the gene for the insulin-like growth factor in the early life of these mice and rates prevented -- when they got to be two years of age or whatever, there was none of the normal decline of function that one ordinarily sees as a result simply of what, of these biological processes of use, whatever the mechanism is, so that the muscle remain vigorous, healthier, repaired themselves better, and showed no sign of decline of the sort that one normally saw in the life cycle. And the point of this question was not to introduce a kind of new set of language where you had to decide whether something was a disease or not. That might only make the thing more complicated. Here there is an underlying biological process of decline which makes us more susceptible to specific known diseases, and in fact, is increasingly vulnerable also to death. And the question is, should we regard this as the kind of thing, as the kind of badness in human life which, with the same kind of medical means that we attack disease, we should set about attacking this, and the attempt to slow it down, arrest it, postpone its onset. Michael. PROF. SANDEL: Well, could I do a shockingly unprofessorial thing, and try to answer your question? And to do it by way of responding to the arguments presented in the paper, the working paper. To answer the question subject to the reasonable qualification that Elizabeth introduced, they were talking about your postponement or extending the good years in Bill's sense, put aside the issue of disease. Extending the average life span such that we would have multiple generations on hand, more than we're used to. That's, I think, the assumption of the paper. And the arguments that the paper presents against doing this, or at least the cautionary considerations that it raises consists of the eight effects, five individual and three social effects, speculative effects of extending the average life span in a way that would extend the good years and produce multiple generations. And I'd like to question those worries, those effects. Sorry, not the effects, but I want to assume that the analysis is more or less correct. Assume for the sake of argument that these would be -- these speculative effects are accurate, that they would -- would that give us cause for worry about this project? That's really the issue this paper presents, as I understand it. And the claim that it would be a cause for worry if these effects really would follow in the wake of age retardation or extending the good years depends on two reasons, two reasons that are implicit in this list of effects. One of them points to disrupting effects. There would be things we would have to adjust to, and the adjustment might be difficult. And the other which carries the moral weight, are dehumanizing or possibly dehumanizing effects. Quite apart from whether we could adjust to these changes, the effects would be undesirable or dehumanizing, maybe indirectly, maybe directly because a longer life span would somehow change human self-understandings in a way that would possibly undermine the background conditions for the exercise of certain virtues or valuable activities. That's the worry that runs through this list of effects. And the question I have is again, that one could quarrel with whether these really are the right effects. But putting that aside, assuming that they are, the question that I came away with is -- goes back to a discussion we had about the moral weight of the given, and here it takes the following form. Are the background conditions in human self-understandings for the virtues just about right now at 78 years of the average life span, or such that they would be eroded and diminished if we extend it to 120 or 150, or 180. But that would be odd if they were just right now. Is it the suggestion that back when it was 48, rather than 78, a century ago, and here's where the retrospective suggestion of Charles kicks in, where the background conditions and self-understanding is sufficiently different, that the virtues we prize were on greater display or more available to us. And if so, would that be reason to aim for, or at least to wish for or long for a shorter life span, rather than a longer one? Now this question arises. You could take the eight [effects] point by point and ask about this. And the one, the individual ones, the five commitment and engagement, the worry is that without an acute sense of our relatively immediately mortality, say within 78 years, that we might have a life of lesser engagements and weakened commitments, but that worry suggests that it would be a bad thing to lighten up, or the postmodern lightness of being, less gravity is -- more detached, more irony is a bad thing. And maybe we've already gone down that path, but does that suggest it might even be better? Maybe it would cure the kind of ills that post modern lightness of being to aim or wish for a shorter life span if this really is an effect that sets the background conditions. Or would we want to say that actually this is also less - lightening up is less in fanaticism and dogmatism of a kind that on balance is a good thing. Or to take the second aspiration and agency, here the idea is that death prods us to achievement. Well, there is -- these days the problem is probably the opposite, that pressures for achievement are so ratcheted up, and we've talked about them in discussion at schools and drugs, that maybe that would be a good thing, or what is the degree? How much spur do we want to achieve, and how soon does death have to loom in order to provide it? If we really want -- if we feel we've become a species of slackers, then that might be a reason to think well, maybe it would be better at 48 or 58, rather than 78, so it can go in both directions. And as for children as the answer to mortality, longevity corresponds to declining birth rates. Well, why assume that the one we've got now is just right? Do we have just the right birth rate now, or do we want a greater or lesser spur to answering our mortality through the generation of more children. Likewise, in the case of the fear of death, that's number four. We don't want the fear of death to become a preoccupation. If people live to 150, the suggestion is, people would really -- it would be very, very risky to -- because you'd be giving up 125 years rather than maybe just, you know, 25 or 30 so people would become too cautious and preoccupied. Well, then there too do we have just the right degree now of preoccupation with death at 78, or -- and is that the right temperament in relation to the willingness to take on life risking activities? Or have we given up a more heroic age that's prompted by well, you're only going to live to 40 or 48 anyhow. Maybe that generates virtues that the heroic, that we should adjust in the other direction. Why assume that 78 is the right degree of heroic activity? And then just to jump to some of the social ones, the worry about there being a glut of the able, or slowing the pace of innovation in companies and in public institutions if they're clogged up with all of these older people, and young people can't get tenure, can't get jobs, there are no openings, that kind of objection. Well, there too, why assume that the one we happen to have at the moment is the right one? Those might be legitimate worries, but if we're really worried about innovation in the kind of highly technological society we have, maybe it would be better to have a quicker turning-over of the generations in military and in schools, and universities and scientific institutions, and in companies. So the general question is, can't we test all of these arguments by saying well, wouldn't we do even better to push it backwards? And the more general question that raises is, doesn't this accord undue moral weight to the given, unless there's some reason to think that with respect to all eight of these virtues we're at just the right point now. CHAIRMAN KASS: Does someone want to join Michael's comment, very interesting comment directly. DR. KRAUTHAMMER: Yes, I would. I had a similar impression. As always, Michael stated it rather eloquently. I think this is not a new question because we have just emerged from the greatest increase in life expectancy in the history of the species. It's been recent and rapid, and we've -- many of us, our parents have lived through it, and we can learn a lot about what might happen from what has happened. I think if we recast the whole issue, it becomes a little less problematic than the way Michael had posed it. If we don't pose the issue of ought we do something about it, or should we start worrying about it? But if we pose it as can we say something intelligent about how we, as society and individuals will change as this revolution accelerates, I think it becomes easier. Then I think what you have in the paper is rather interesting, rich, and contributes to a debate in thinking about it, rather than -- I mean, once we start thinking about regulation or pronouncements about whether this stuff is good or bad, we're going to get into all kinds of troubles. And I think Michael is right, if you look at it retroactively, you'd want to argue for a decrease in our life span. I think it's useful for us as a body to have a paper which will be a decade or two ahead of the curve, and say something like we're entering a revolution in life expectancy. We've lived through one which was, as you said, disease-specific, but now we're going to perhaps enter a threshold where we're going to increase life expectancy by actually attacking the process of aging itself, which may increase life expectancy by multiples. And here is what -- how it might affect society, and here we might want to think about these long-range effects. I think if we stray beyond that advisory or sort of analytic approach, we're going to run into the problems that Michael has identified. In fact, given the choice, if people have been asked the question we are asking 100 years ago, I think they would have said let's try to extend life expectancy and see how it develops. And I would say that on balance, it's been a pretty good experiment, and the species has done rather well. I would find it very hard to argue against -- it's beyond hard. I think it would be odd if we were to as a body begin to argue against or question the value of this enterprise. I think the best that we can do is to say here are the problems which might arise. Let's start thinking about them. CHAIRMAN KASS: Mary Ann. PROF. GLENDON: Well, we're distinguishing between prolonging life and alleviating the symptoms of decline. And as a practical matter, when we're trying to figure out what the consequences of one or the other will be for society, as a practical matter, this is a question for the medical people, isn't it the case that what is likely to happen in the foreseeable future is that we are much more likely, we are, in fact, in the process of prolonging longevity while not alleviating those processes, whether you call them -- whether they are the real diseases, or whether they are just the process of senescence itself. And isn't this the most immediate problem that we have to think about as a society, is prolongation of life, but life that will still be characterized by -- well, put it another way, prolonging that period of senescence. That's one observation. The other is that we sometimes start out our discussions with a literary piece that raises the issues, and I wonder if any of you have read the poem by Oliver Wendell Holmes, the elder, called "The Wonderful One-Horse Shay". He remembers that people went to school in New England all had to learn that poem. Now Oliver Wendell Holmes, the elder, was a medical doctor, a very distinguished medical doctor, as well as a literary man, and he wrote this poem that I think is a reflection on the very problem that we're discussing. He discusses this beautifully constructed carriage, horse-drawn carriage that's constructed in the previous century. And this carriage functioned well for 100 years, and then one day they opened the carriage house and there it was just all disassembled into its various pieces. Now what was Holmes thinking about? I think the poem is about a longing that all of us have. I mean, whether it's worthy, or noble or rational, most people would like to just live with all of faculties in tact until they fall into their various pieces. Now I know that's probably not the philosophic, it's not the "Meditation on the Life Worth Living", and all that, and it's not "Meditation on Preparing to Die", but I think, you know, most of us in our heart of hearts would say boy, that would be a good way to go so, Leon, I took your question to be, is that really what we should want is something like that? CHAIRMAN KASS: Let's see. Bill, and then Gil. DR. HURLBUT: Oliver Wendell Holmes also wrote a poem called, "The Chambered Nautilus", "Build ye more stately mansions oh, my soul as the swift seasons role, leave thy low vaulted past, that each new temple nobler than the last", and so forth, implying that there was a progression over life that somehow expanded our comprehension of existence and gave us a meaningful completion. And it seems to me that one of the fundamental questions is whether those increasingly large chambers somehow involve the kind of life experience that's implied by an aging and suffering individual, or whether -- and whether we could disrupt that. The image to me of life extension that comes to mind is like a symphony. It seems to me that if you play a symphony much slower than normal, it won't be very good any more, that there comes a point where you've lost the artistic coherence of the thing. But this raises a real interesting question, and Michael made a comment that bothered me the whole time I was reading the paper too, and not that I disagree at all with the sentiment of the paper, but I kept thinking where did we ever get this notion that life was supposed to be three score and ten? How come that's in the Bible when everybody on average was dying at 50? And the only thing I could think of was that well, maybe they observed that you can get the impression that somebody who dies at 80, died of old age. But somebody who died before that, died of an acute disease or prematurely. So then you think to yourself well, why do we feel like a good life ought to be three score and ten? Wouldn't you think that if there is a meaningful life, it ought to be the life that was woven in coherence with our physical process in the environment of evolutionary adaptation in which both our mind and our body would be coordinated. This strangely suggests that life was somehow created by a benevolent force that had in mind some improvement in which we would finally find our fullness, who knows, by technology or so forth. Now I don't want to get into the question of whether -- how the world was created, but the implication in the paper is that somehow or another we've arrived at this little point in technology where things are good, but if we keep going, we'll make them bad. But I want to point out something interesting in all this. At the same time that the life span has been increasing, the age of the onset of puberty, at least in young women over the last 200 years has declined, the so-called secular trend, so that actually life happens -- we've unbalanced the life span with our technology. In this case, it was just better food it seems, but it raises a really interesting question, because I think we sort of feel the disorder of that. I don't know. I mean, that's a hard call, but it does seem to me that children entering puberty earlier and earlier is a disruptive effect on life process in time as people live longer, which is a good process. That then suggests that maybe the advent of technology wasn't the whole solution to what was missing in the environment of evolutionary adaptation. You see the distinction I'm making? It's kind of a mysterious category because I remember very well when we went to see President Bush the first day of our meeting, our first meeting, and after his prepared comments, he kind of spoke extemporaneously, and he sort of leaned forward to us and he said, you know that there is a creator, and beneath it all, it seems to me that's a very profound comment, because how do we know what would make a good life, and who's behind all this? What is it that actually will draw us to that coherence which is meaningful? And anyway, why should we assume there is meaning in life that is present in one state and not in the other? That's a -- there's a cosmology under there, and I don't mean to over-stress that, that it has to be a theistic creator or notion like that, but somehow or another we do have this image of what makes a good and coherent, and meaningful life, and the worry that we might just walk ourselves out of it, write ourselves right out of our own story. CHAIRMAN KASS: Gil. PROF. MEILAENDER: Yes. Listening to Michael and Charles, and Mary Ann and Bill actually brings me back to Elizabeth's images at the start. And I'm still trying to sort out my puzzles from before. It seems to me that we really do need to distinguish two kinds of -- two different questions, because they call for different sorts of answers, or they might call for different sorts of answers anyway. One is the question, would a longer life span be problematic? And if somebody asked you to answer that question, Michael's cautions might be in order, or you might not be -- you might not think you could give, or necessarily even being asked to give a definitive answer, but simply to sort through a number of possible effects of such a longer life span. The other sort of question one might ask is, would it be better not to have a period of decline? And that's a different sort of question, because on the one hand, of course, you could also think through consequences and so forth with it, but also it's just asking a more straightforward question about kind of what would be a good life for a human being. And I think that those are somewhat different kinds of answers with the -- just, you know, would we better off with a longer life span? Well, it's complicated, you know, and kind of hard to sort out. There are some interesting things to speculate about, and they're worth speculating about. We should be ahead of the curve as Charles says, and so forth, but I'm not sure exactly how one says more than that. Would it be better not to have a period of decline? I don't know. That's a different sort of question, I think, that calls for a little different kind of answer, so it seems to me anyway. CHAIRMAN KASS: Having brought up the second question, do you want to put your toe in the water on it? PROF. MEILAENDER: I think it's what -- I think Mary Ann is right, that it's what -- I don't know about most, but many, many people want today. What people really want is to live at something -- they don't want not to age at all. I mean, they don't mind having grandchildren as long as they're still kind of peppy, that is to say, that the grandparent is still peppy and able to do whatever they want, and so what we'd like to do is kind of live at a really high level and then just drop off the map suddenly, your two seconds of mortality, Elizabeth. And I understand the appeal of that. I guess you probably understand the appeal more and more as the years go by in some ways, but I think that would be bad. It would lose something essential in the kind of trajectory of a biological organism, which we are in part, and which we need to come to terms with. And it would, in a sense, as you, yourself have argued in the past, Leon, make it kind of harder to acknowledge the reality of death. So my toe in the water says with the second question, no, it would be a bad thing not to have a period of decline, that some people suffer horribly in it, you know, and it's terrible I understand, but not to have it, that would be bad. CHAIRMAN KASS: Mary Ann. PROF. GLENDON: Well, again just thinking of literary examples. It was at one time thought the worst thing you could wish for your worst enemy was that the person would have a sudden death, which is exactly what many people wish for themselves. I mean, how many people have you heard say I hope I get my heart attack. PROF. BLACKBURN: But, Mary Ann, wasn't that mostly implying a premature death? I think it was the prematurity rather than -- PROF. GLENDON: No, a death without opportunity to come to terms with -- PROF. BLACKBURN:Without preparation. I see. Okay. CHAIRMAN KASS: Bill. DR. MAY: I think it was Kierkegaard in the 19th Century said it was the modern world that tends to associate a good death with a sudden one. He found that rather odd because, of course, the prayers and the Catholic tradition talked about an evil of sudden and unprovided for death, and so a time of warning. Now it is the case, of course, most deaths occurred rather rapidly earlier, and they didn't have the artificial prolongation of life that we've had possible to us recently. I worry in the discussion, the unspoken assumption that we're dealing with life in unilinear terms, from a beginning to an end, and then you stretch that line, or then you begin to discuss a fattening of the line, that's the good years. And then the line thins out when you enter into a decline. And there was a certain differing -- and then we associate, therefore, all of this with the medical problem, the physical problem, whether our physical life suffers a decline in resources that allow us to mount these fat years, these good years. And we'd merely be prolonging lean years, and nobody wants that. And what all this misses is something that in traditional society we're vividly aware of, that death is not simply the event at the end of life, but nor is it simply the event that relates to decline. But life suffers terrific interventions in the course of life, which are reminders of death, and of our mortality. And it's not the case that if we provided the physical base for an expanded life, that we have somehow eliminated the constricting experience and crisis of death in the course of life. And, of course, traditional society's puberty rite appropriately included the whipping, the tattooing or the pulling of a tooth or something to remind people that you're undergoing an alteration of identity from going from childhood to adult life. And it's -- the death experience relates to those experiences of alteration and identity in the course of life. It is not simply that that's a moment at the end of life, so I'm not sure it's the case in this discussion of extending life, that therefore, we have not prepared ourselves for the problem of death. That assumes it's only the death experience at the end of life. There are all sorts of ways in which people are going to have to come to terms with death, even if they enjoy relatively good health, good counts on blood pressure and all these other things that we take as indices of well-being and life. I don't think we're going to be removed from the problem of dealing with our finitude, our mortality simply by extending life, as this paper tends to suggest. CHAIRMAN KASS: Paul. DR. McHUGH: I'm just going to continue some of our literary associations. I'm with Mary Ann, and I go with the idea that "Twixt the stirrup and the ground, many have sought salvation found." It can come quick, and it can happen, and it'll be okay. And I also wish to see things that could be extended with a good life. Again, speaking in New England literary terms because I have "promises to keep and miles to go before I sleep." We've got a ways to go. We've got more promises, and we'd like to keep them. On the other hand, what's going to happen in my opinion, as I said before, is that we're tackling diseases, and in that process, finding out pathological mechanisms that in minor form are the essences of aging. They include oxidative injuries, and they include replicative injuries and exhaustions that Elizabeth could talk about far better than I have. And that ultimately, those kinds of slow injuries, the aging that Gil is saying are in fact going on all the time, it would be useful, I think, to be able to slow them a bit. I don't think you can eliminate them and be ultimately iron-rust. The one-horse shay falls apart. We are material, and this material is going to be afflicted, but could we extend it longer? Yes, I think we will. And in fact, when we do discover more about disease, those things will be available to us. Whether it will take the form like everybody else is popping Vitamin E or not, I think there will be things of that sort. And it will happen, and then just what Michael has predicted, we'll adjust to that. And by the way, I want to be on record to say that it would be a good thing to adjust to those problems. I'm ready. CHAIRMAN KASS: Robby. PROF. GEORGE: I suspect that the worry among people who do worry about the project that we're talking about here is that our apprehension and understanding, and our possibility of an accurate understanding of the meaning of life or its aspects is somehow connected to our understanding of the meaning of death. Is death a natural part of life, or ought we to conceive death as something other than a natural part of life? And I suspect that the worry is that if we conceive it as something other than a natural part of life, that that will effect broadly people's understanding of the meaning in life. Leon, you and Bill May, and Gil probably have at the tip of your tongues what I'm searching for here, but there are some passages in Plato where he talks about the importance of understanding your activities today, shaping your activities today in the shadow of your death. When you see the problems that you face today, and you make the decisions and choices that you make today, having in mind your death, you make better -- your understanding is better. You make better choices. You're more likely to act in a human and humane way. Now I think that those -- that that's considered, the worry about what death will mean to people, how people understand death, and then the impact on their understanding of the meaning of life, their capacity accurately to understand the aspects of the meaning of life, probably isn't reducible to the considerations that were adduced in the paper, and that could be addressed analytically, as Charles said. So although I'm not able certainly off the top of my head to articulate the alternative here very clearly, it doesn't seem to me that it really is addressed by Michael's critique of what is in the paper, these considerations about social effects, having to do with the laying of childbearing and so forth and so on. I think it's something else like how people will conceive death and the meaning of death, or the relation of death to life, or the role of death in life, and therefore, the impact on their understandings and choices today. Sorry I can't do better than that, but I think if we don't get something like that on the table, we may be really missing the core of the worry about this. CHAIRMAN KASS: Yeah. I mean, part of the reason that doesn't show up is that I think the Staff paper was not conceived of as being about the mortality project, which would have made that absolutely vivid, though there is a certain suggestion, I think, in one of the places where tacitly if you somehow say all decline is somehow regrettable, that ultimately you're really saying whether you know it or not, that the real name of the game is to prevent the ultimate decline and disappearance. PROF. SANDEL: But unless that claim is convincing, and so far I don't think it's been made convincing, there are two separate issues, as you say. Banishing immortality being one, prolonging life or retarding aging being the other. And the paper, to be fair to the paper, addresses not the banishment of immortality, but the prolongation of life. CHAIRMAN KASS: Indeed. Indeed. PROF. GEORGE: Well, I just want to flag that although the distinction is there, and I understand it, as a practical matter for purposes of the worry, I don't know if it can drawn all that sharply, because if it's true - I don't know whether it's true. I don't know how we would even go about trying to figure out whether it's true. If prolongation of a certain sort, a certain length or achieved in a certain way has the impact of, in effect, banishing death from the mind, or changing our attitude toward death in a way that has this putatively deleterious effect on our capacity to understand our actions in the shadow of death and, therefore, the meaning of life, then we've got the same problem, whether it's prolongation or banishment. PROF. SANDEL: Well, someone would have to try to flush out that case. I don't think anybody has done that, and Bill gives reasons to think that it's probably an implausible case, but someone could try. It would be interesting if someone were to try. So far that hasn't been produced. CHAIRMAN KASS: Yeah. Let me respond, Michael, to your comment which I'm not so sure I would have characterized as a critique of what's in the paper, as much as filling out of what was somehow implied by raising those kinds of questions. And your sort of deft way of saying well, wouldn't this kind of concern maybe lead us to wonder whether we should have a shorter life, reverse some of the things. And having done that, would it be an embarrassment to someone who complacently thought that the given was the best, that this was the best of all possible worlds. But having provoked the question, doesn't somehow that paralyze us before the necessity of addressing it? PROF. SANDEL: Oh, I agree. CHAIRMAN KASS: And in that sense, it does seem to me that -- would you not say that, maybe it's not an exhaustive list, but at least the paper does touch on certain aspects of our existence that might be affected, and might be affected for better, or might be affected for worse. And rather than say well, the precedent that we've gotten used to the world of modest longevity implies that we will get used to the world of super longevity and, therefore, it's cost-free or good, doesn't that in a way compel us -- PROF. SANDEL: That wasn't my claim. That's closer to the spirit of Charles and Paul. That's not what I was saying. I would say it's not a knockdown argument against this to say you open the question whether to push it back. I would say yes, so I'm agreeing that you could take it in both ways. CHAIRMAN KASS: Then let me try you on one particular piece of -- I mean, you spoke mostly about the -- I mean, you could have gone on, had you wanted to, I'm sure, to tackle some of the social aspects as much as the individual ones, but take the question of pursuit of our preservation, longevity and well-being, and its relation to the willingness to be devoted to those who will replace us. On balance, how do you think this plays out? PROF. SANDEL: Will we be less devoted to those who -- to successive generations, to our children and grandchildren if we live longer and see more generations, more great-grandchildren? Is that what -- CHAIRMAN KASS: Well, there was no procreation in the Garden of Eden, where the possibility of indefinite life was just a reach away. No one had any interest in it, not having discovered that death was bad. But the suggestion seems to be that the blessed pain-free, joyous life for one's self is perhaps at odds with the willingness to make way for and demote one's self to those who will replace one, especially if the replacement seems more and more optional. It's not meant to be an assert -- it's meant to be -- raise a serious question. Biology is quite interesting on this, because there seems to be some interesting connections between these things which sort of produce longevity and actually get in the way of fertility, and the connection with -- and there are lots of possible explanations of this. But we had some discussion when our experts were here, and was there some speculation on the connection between puberty and fertility on the one hand, and a switch that might, in fact, lead down the road to decline and disappearance? PROF. SANDEL: It's a good question. My intuition, if I knew I would live to 150 or expected to, would I be less likely to have kids, or would I have fewer kids? Intuitively no, I don't get it, but I don't know. What makes you think that I would? CHAIRMAN KASS: Well, I'm struck by just a number of things. The declining birth rate in places of prosperity and longevity is an interesting fact. And it's not obvious to me that those of us who have really prospered under the blessings of prosperity and good health for a long time see our place in the world as those who are somehow going to make a better life for our children, as much as we're going to see it as an opportunity to fulfill ourselves here and now. DR. MAY: It's an interesting issue on education. After all, at the end of World War II our expenditures for education and health care and defense for a while were roughly comparable, and now health care has zoomed over 14 percent, and education is still down there at 5 to 6 percent. That's not the issue that you raise in this paper. You raise it more in personal terms. The next generation would be less inclined to invest in the education of the young. I found it amusing to think, however, that in this paper that if I were to cut down my caloric intake down to 60 percent, it would not be a public spirited act on my part. I mean, living longer and soaking up resources and so forth, so obviously the paper does not lead in the direction of regulations, but it is a cautionary note. And the caution ought to impinge on such questions as how we invest our resources, and whether this becomes a top priority issue in the future, or whether we are already lopsidedly investing in health care, as compared with other kinds of investments we ought to be making for the welfare of future generations. DR. KRAUTHAMMER: But on that point, it might be a useful contribution to the question of how we distribute the resources within the amounts allocated for health care. In other words, it might make more sense to invest money on retarding the aging process than on going after Disease X, Y and Z, because in the end, your -- I mean, presumably if you went after aging, you'd be extending this period of health and vigor, rather than substituting one way of dying for another, which is what a lot of the disease-specific stuff is doing. Just an aside on that point. One other -- just as another aside, that the best verdict on what life expectancy does to how you lead your life I think came from Mickey Mantle, whom as you know, lead a rather wild and raucous life. When he died in his late 50s, he said if I had known I was going to live this long, I would have taken care of myself. And that's because he had a father, and uncle and a brother, all of whom died early of heart disease in their 40s. He expected he would too, so he didn't really take care of himself. CHAIRMAN KASS: Rebecca and Dan. DR. FOSTER: One quick comment about the health cost. A very large portion of the health costs in the country are at the end of life expenditures, where there's not, if you look at Medicare and so forth, I mean it -- so an economic problem is if you're going to continue to treat diseases, they have longer to develop and so forth, unless you can stop all that. I mean, the costs of prolonging life are very huge, because it's the highest cost that we have right now. CHAIRMAN KASS: Rebecca, and then I think we'll close. PROF. DRESSER: A bunch of disjointed comments. One is, I don't know -- your original question, is this a medical problem? If it's not a medical problem, if it's considered a social problem to deal with just the senescence process, I think it will get just as much attention from society, if not more. It will be like our impaired mobility. I mean, people will invent cars, you know, outside of the medical model, so in fact, it might get treated in a more sort of crass commercial way if it's not defined as a medical problem. I do think that this paper has an inherent tone of conservatism, and we live in the best of all possible worlds. And I notice that at the beginning you said the case in favor of living longer hardly needs to be made in detail, and so if we focus more on the drawbacks than the advantages, it's not because the advantages are not lacking. But I think that that's one thing that gives it this tone of well, let's -- what we have now is the best, and let's think about all the bad things that would happen if we changed it. So I mean, I think we should concede that -- just think of the opportunities for human flourishing that would expand. You could have different careers. I could go back and study the classics that I missed by being a social science major. I mean, there would be lots of positives, so I certainly agree that there are concerns, but I think it comes off as, you know, as I said essentially let's preserve the status quo. And I'm not sure that we want to -- I think we want to be more exploratory. For me, if we want to -- I thought Michael's statement was really great. For me to inject an evaluative note on whether what we have now is better than what we would have if this aging, if the healthy part of aging were extended. We have to look at something objective like constraints on natural resources and sustainability. To me, the social effects are the most concerning, and there does seem to be an element of selfishness in some of this, and so I wonder if tying some of these concerns to the Mother Earth and limited resources, maybe we'll go to other planets or whatever, but it does -- that, to me, seems to have -- gives some grounding that otherwise you say well, why don't we have shorter? Why don't we have longer? We don't have that grounding. And then finally, to quibble, I do think that this -- the effect of reduced fertility and people wouldn't want to have children as much, I really question that. And I guess the explanation I've heard for the decrease in the birth rate we've had is because when children live longer, people don't feel they have to have 10 children and hope that they'll end up with two. And then the other thing is the availability of contraceptives, and changing gender roles. I guess those are the things I've heard demographically that have explained a lot of the declining birth rate, with economic prosperity, so I would just be really cautious about explaining our increased life expectancy as one of the reasons that people are having fewer children. I don't know what those social science data are on that. CHAIRMAN KASS: Does someone want a last word? DR. MAY: A limited comment, innovation and change. It seems to me the argument that's given here is that you people will be in full vigor, and you won't be able to blast them out of their jobs. And then the big time institutions where they work will, therefore, not change as much. It's quite possible there would be another reading, people having the time after their jobs to be involved in so-called third-sector institutions, which have been very important to the vigor of this country, and a source of innovation and change. And as I recall back in Vatican Council II, my Catholic friends sometimes said the most conservative generation was the "fortress" generation, that was in charge, but those were in the earlier stages of life, and those in the later stages of life were most disposed to be more venturesome about what was happening, so I think one might give a different reading about some of those social impacts. CHAIRMAN KASS: Well, we are adjourned until 2:00. Please try to be prompt. We have Steven Pinker as a guest, and we'd like to start on time. Thank you. (Off the record 12:32 - 2:03 p.m.) Session 3: Human Nature and Its Future CHAIRMAN KASS: Well, I think we should get started. We have a few stragglers who will, I'm sure, wander in promptly. The topic this afternoon is for the first time in our meetings the subject of human nature and human nature in the age of biotechnology. The subject crops up now and then in our conversations and is very often just below the surface as one talks about various kinds of technical innovations which at least some people claim might produce certain kinds of changes in human nature. And in these kinds of conversations very quickly one gets into questions of whether there is such a thing as human nature, whether there is something fixed and hard wired, or whether it's primarily plastic, or whether, as is frequently said, it is the course of the essence of human nature to change human nature, and on and on and on. There have also been some conversations here where human nature has functioned not simply descriptively, but also normatively as something which is either thought to be sacrosanct and offering some kind of guidance or, on the contrary, as something which is so filled with flaws that it needs, in fact, to be improved, our senescence in mortality being one amongst those flaws that we discussed improving in the session before lunch. And it seems to me that we thought it was worthwhile to actually make this a subject of explicit conversation and spend some time on it. This is not a public policy question. There are not going to be recommendations. There are not even going to be "thou shalts" and "thou shalt nots" coming out of this, but it does seem to me it's worth our while to pay some attention to this larger theme in an explicit way, and especially to think about how to think about human nature in an age of genomics, in an age of neuroscience, both how we should understand it, to understand what might be possible in the way of altering it and ultimately what those alterations might mean and whether they would be a good thing, large questions all, and we are very lucky to have as our special guest someone for whom these large questions are, to say the least, not daunting because he's willing to step forward and speak about them, and that's Professor Steven Pinker, a neuroscientist and evolutionary psychologist and a very gifted and prolific, popular author about these matters. He's the Peter D. Florez Professor in the Department of Brain and Cognitive Science at MIT, the author of recent books, How the Mind Works, and more recently The Blank Slate, and he has very kindly agreed to come and introduce us to this topic with a formal presentation after which all of us look forward to having conversation with you. Thank you very much and welcome, DR. PINKER: Thank you very much. I'd like to thank Dr. Kass for the opportunity to speak to this group. It is really an honor and a privilege to share these ideas with you. Thank you. I'm going to talk about the modest topic of the past, present, and future of human nature with an emphasis on the future. What about the past? In much of the 20th Century, there was a widespread denial of the existence of human nature in Western intellectual life, and I will just present three representative quotations. "Man has no nature," from the philosopher Jose Ortega y Gassett. "Man has no instincts," from the anthropologist and public intellectual Ashley Montagu. "The human brain is capable of a full range of behaviors and predisposed to none," from the evolutionary biologist Stephen Jay Gould. I think, however, that in recent times there has been a rediscovery and a reacknowledgement of the idea that humans have a nature as well as a history. Partly it's an acknowledgement of common sense. Anyone who has had more than one child knows that children are not indistinguishable lumps of putty waiting to be changed, but come into the world with certain talents and temperaments. Anyone who has both children and house pets has surely noticed that the children exposed to language will develop language, in turn, whereas the house pets will not. There has also been a reacknowledgement of universals across human societies, although it's undeniable that human societies and cultures differ from one another in countless ways. There is also a large stock of universal behaviors and emotions that can be found in all of the world's 6,000 cultures. Here is a list recently compiled by the anthropologist Donald Brown that goes from aesthetics, affection, and ambivalence all the way down to fallow contrasts, weaning, weapons, and attempts to control the weather. There has also been an increasing body of data from behavioral genetics and cognitive neuroscience, suggesting that the human brain has a complex inherent structure. This is a recent study from Paul Thompson and colleagues based on earlier work from your own Mike Gazzaniga, which used magnetic resonance imaging to measure the distribution of gray matter in different parts of the cerebral cortex and correlated it across a large sample of pairs of individuals. They coded the correlation in false color so that zero correlation was represented in shades of blue and purple, and statistically significant correlation in shades of green, red, and pink. Now, by definition if you pick people at random and correlate the gray matter in different parts of the brain, the correlation will be zero, and so in unrelated subjects you have view of the left hemisphere, the right hemisphere, and a top view that is uniformly zero. This is what happens in pairs of people who share half their genes, namely fraternal twins. As you can see, most of the cortex shows statistically significant correlations in how much gray matter is found in different areas. This is what happens in people who share all of their genes, namely, identical or monozygotic twins, and as you can see, they're even greater extents of cortex that are highly correlated across pairs of individuals. Now, these correlations are not just meaningless anatomical shapes like the shape of your earlobes, but have behavioral consequences, and studies of twins and adoptees have shown substantial genetic influences on personality and intellect. My favorite summary is from the Charles Addams cartoon in The New Yorker whose caption is "separated at birth, the Malliefert twins meet accidentally," showing a pair of inventors with identical contraptions in their laps in the waiting room of a patent attorney. The cartoon is not such an exaggeration on the data. Studies of identical twins who are separated at birth and reunited in adulthood show that they share astonishing similarities in their personalities, in their intellects, and even in individual quirks, like dipping buttered toast in coffee and wearing rubber bands around their wrists. Well, that's the past and the present. Given that human nature exists as common sense and the empirical data tell us, does that mean that we can change it? Now, there have been some notorious attempts to change human nature that we've seen in the 20th Century. There has been the attempt to socially engineer a new man, in particular, a new socialist man leading to the totalitarian regimes in the Marxist dictatorships in Russia, China, and Cambodia. I think it's fair to say that this is no longer a topic of debate among decent individuals. Equally horrific has been the attempt to change human nature through eugenics both in the case of mandatory of sterilization that was widespread in many Western countries, including the United States, until the 1930s, and even more horrifically, the Nazi genocide, which was predicated on the desirability of changing human nature through sterilization and mass murder. I'm going to talk about the ability to change human nature that's of more direct interest to the members of this committee, namely, voluntary genetic engineering, popularly known as designer babies, and that will be the topic of the rest of my presentation. I don't have to remind you that this is ethically fraught, and there are vociferous voices arguing that this would be a bad thing or that it would be a good thing. I'm going to address a common assumption both of people who are alarmed and people who welcome genetic enhancement. The assumption that this is inevitable, that science has reached the point where it's only a matter of time before genetic enhancement is routine and possibly the human species will change unless we intervene and regulate the science and practice now. I'm going to present a skeptical argument about designer babies to give you an overview. I'm going to suggest that genetic enhancement of human nature is not inevitable. Indeed, I would be willing to venture that it's highly unlikely in our lifetimes. Why? First of all, because of the fallibility of predictions about complex technology in general. Secondly, impediments to genetic enhancement from what we know about the human behavioral genetics. And, third, impediments from human nature itself. Well, let me begin with the frailty of technological predictions in general. There's a wonderful book called The Experts Speak by Victor Navasky and Christopher Cerf which has some delicious quotations about what is inevitable in our future, such as the following one. "Fifty years hence we shall escape the absurdity of growing a whole chicken in order to eat the breast or wing by growing these parts separately under a suitable medium," Winston Churchill in 1932. That should have happened by 1982, and we're still waiting. Nuclear powered vacuum cleaners will probably be a reality within ten years, a prediction made in 1955 by a manufacturer of vacuum cleaners. A few other predictions that I remember from my childhood, and in fact, from newspapers of just a few years ago. Dome cities, jet pack commuting, mile high buildings, routine artificial organs, routine consumer space flights, such as the Pan Am shuttle to the moon featured in 2001, interactive television, the paperless office, and the dot-com revolution and the end of bricks-and-mortar retail. All of these predictions we know to be false, and a number of them are not even developments that have not happened yet, but things that we can say with a fair amount of confidence never will happen. We're not going to have domed cities, at least not in the future that's worth worrying about. Now, why are technological predictions so often wrong? First, there's a habit of assuming that technological progress can be linearly extrapolated. If there's a little bit of progress now, there will be proportional progress as we multiply the number of years out. Engineers sometimes refer to this as the fallacy of thinking that we can get to the moon by climbing trees. A little bit of progress now can be extended indefinitely. Secondly, there's a tendency to underestimate the number of things that have to go exactly right for a given scenario to take place. Most technological changes don't depend on a single discovery, but rather on an enormous number of factors, scores or even hundreds, all of which have to fall into place exactly right. Both technological developments, psychological developments, namely, whether individual humans will opt for the technology both in developing it and in adopting it, and sociological factors, namely, whether there will be a multiplication of those choices society-wide that will lead to the economies of scale and the social pressures that would lead to some technological development becoming ubiquitous. Third, there's a widespread failure of futurologists to consider the costs of new technologies, as well as the benefits, whereas in reality the actual users faced with a particular technology consider both the benefits and the costs. Finally, there is an incentive structure to futurology. Someone who predicts a future that's radically different from our own, either to hype it or to raise an alarm against it will get the attention of the press and the public. The chances are The New York Times won't call you up if you say either that the future is going to be pretty similar to the present or we haven't a clue as to what the future will be. The second part of my talk, reasons for skepticism about designer babies is that there's a considerably bracing splash of cold water on the possibility of designer babies from what we know about behavioral genetics and neural development today. There's a widespread assumption that we have discovered or soon will discover individual genes for talents such as mathematical giftedness, musical talent, athletic prowess, and so on. But the reality is considerably different, and I think an Achilles heel of genetic enhancement will be the rarity of single genes with consistent beneficial psychological effects. I think there's a myth that such genes have been discovered or inevitably will be discovered, but it isn't necessarily so. Indeed, I would say that the science of behavioral genetics at present faces something of a paradox. We know that tens of thousands of genes working together have a large effect on the mind. We know that from twin studies that show that identical twins are far more similar than fraternal twins who, in turn, are more similar than unrelated individuals, and from adoption studies that show that children resemble their biological parents more than their adopted parents. But these are effects of sharing an entire genome or half of a genome or a quarter of a genome. It's very different from the existence of single genes that have a consistent effect on the mind, which have been few and far between. Anyone who has kept up with the literature on behavioral genetics has noticed that there's been a widespread failure to find single genes for schizophrenia, autism, obsessive-compulsive disorder, and so on. And those, by the way, are the areas where we're most likely to find a single gene simply because it's easier to disrupt a complex system with a single defective part than it is to install an entire complex ability with a single gene. The failure to find a gene with consistent effect on, say, schizophrenia means that it's even less likely that we will find a gene for something as complex as musical talent or likability. And though there have been highly publicized discoveries of single genes for syndromes such as bipolar illness, sexual orientation, or in perhaps the most promising case, a gene that appeared to correlate with four IQ points in gifted individuals; all of those discoveries have been withdrawn in recent years, including the four point IQ gene withdrawn just last month. Now, it's really not such a paradox when you think about what we know about biological development in general. The human brain is not a bag of traits with one gene for each trait. That's just not the way genetics works. Neural development is a staggering complex process which we are only beginning to get the first clues about. It involves many genes interacting in complex feedback loops. The effects of genes are often non-additive. The effect of one gene and the effect of a second gene don't produce the sum of their effects when they're simultaneously present necessarily. The pattern of expression of genes is often as important as which genes are present, and therefore, it's a good idea not to hold your breath for the discovery of the musical talent gene or any other single gene or small number of genes with a large, consistent effect on cognitive functioning or personality. As an analogy, we know that the code that comes with a software package, that is a software package obviously determines the operation of a computer, and we know that properties of a computer package, such as how easy it is to use depend intimately, completely on the sequence of instructions in the software. That doesn't mean that there is a single instruction that you can insert into a computer program that will make it easy to use, nor a single instruction that you can remove that will automatically make it hard to use. I think there are other genetic impediments to the possibility of genetic enhancement. One is that the genes, even acting across an entire genome, have effects that are, at best, probabilistic. A sobering discovery is that monozygotic twins reared together who share all of their genes and most of their environment are imperfectly correlated. When it comes to personality measures, such as extroversion or neuroticism, correlations are in the range of .5. Now, that's much, much bigger than correlations among non-identical twins or, let alone, unrelated individuals, but it's much less than one, and what that tells us is that there is an enormous and generally unacknowledged role for chance in the development of a human being. Secondly, there's a phenomenon of pleiotropy that most genes have multiple effects, and in general, evolution selects for the best compromise among the positive and negative effects that come from an individual gene. A vivid example of this is aside from the four point IQ gene, probably the best candidate for a gene with the potential for enhancement is the knock-in mice reported two years ago that were given extra MNDA receptors, receptors that are critical to learning and memory. These were artificially engineered mice that had an enhanced ability to learn mazes. On the other hand, it was later discovered that these mice were hypersensitive to inflammatory pain. So a genetic change had both a positive and negative effects. Because of this, it means that there are ethical impediments to research on human enhancement, namely, how can you get there from here. Are there experiments that a typical human subjects committee would approve of, given the likelihood that any given gene will have negative effects on a child, in addition to the positive ones. Finally, most human traits are desirable at intermediate values. Wallace Simpson famously said that you can't be too rich or too thin, and it may be true that you can't be too smart, but for most other traits, you really can have too much of a good thing. Most parents don't want their child to be not assertive enough, to be a punching bag or a door mat. On the other hand, most parents would also not want their child to be Jack the Ripper. You want your child to have some degree of risk taking, not to sit at home cowering out of fear of negative consequences. On the other hand, you don't want a self-destructive maniac either. So if a given gene, even if it did have as its effect an enhancement, say, of risk taking, put it in a child and you'll have ten extra points on the risk taking scale; the crucial question is: what are the other 29,999 genes doing? Would they be placing your child on the left-hand side of the Bell curve, in which case an extra dose of assertiveness would be a good thing, or have they already put your child on the right-hand side of the Bell curve so that an extra dose of assertiveness is the last thing that you would want? The third part of the argument is I think there are impediments in human nature to enhancing human nature. Now, one feature of parental psychology that is often invoked in these discussions is the desire of parents to give their children whatever boost is possible, and lurking in all of these discussions is the stereotype of the Yuppie parent who plays Mozart to the mother's belly while the mother is pregnant, bombards the baby with flash cards, has them taking violin lessons at the age of three, and so on. And the assumption is that parents would stop at nothing to enhance their children's ability, including genetic engineering. Well, that obviously is a feature of parental psychology, but there's a second feature of parental psychology that also has to be factored in, namely, the aversion to harm your children. Most parents know that even if they are not sure whether playing Mozart to a pregnant woman's belly will help their child, they have reasonable belief that it couldn't harm the child. Likewise the flash cards, the violin lessons, and so on. If it came to genetic enhancement where this was unknown, it's not so clear that parents would opt for the risk of doing their children genuine harm for the promise of a possibility of doing them good. Also, one ubiquitous feature of human nature is intuitions about naturalness and contamination, sometimes referred to by cognitive psychologists as psychological essentialism, the folk belief that living things have an essence which can be contaminated by pollutants from without. This has been an impediment to the acceptance of other technologies. Famous examples are nuclear power, which is notoriously aversive to large segments of the population. As you all know, there hasn't been a new nuclear power plant built in this country for several decades, despite the possibility that it could be an effective solution to global warming. In Europe and in large segments of this country, there is a widespread repugnance to genetically modified foods for reasons that are probably more irrational than rational, but nonetheless cannot be gainsaid. If people have a horror about genetically modified soybeans, it's not so clear that they would rush to welcome genetically modified children. Finally, anyone who knows someone who has undergone IVF knows that this is a traumatic, painful, and rather unpleasant procedure, especially in comparison to sex. While there are undoubtedly extremists who would use IVF, we know that they would use IVF for things as trivial as having their child born under a certain astrological sign; it's certainly not true that everyone would shun IVF for trivial reasons. There is reason to believe that this would not necessarily catch on in the population as a whole. So the choice that parents would face in a hypothetical future in which even if genetic enhancement were possible would not be the one that's popularly portrayed, namely, would you opt for a procedure that would give you a happier and more talented child. When you put it like that, well, who would say no to that question? More realistically, the question that parents would face would be something like this. Would you opt for a traumatic and expensive procedure that might give you a very slightly happier and more talented child, might give you a less happy, less talented child, might give you a deformed child, and probably would do nothing. We don't know the probabilities of those four outcomes. I think this is a more realistic way of thinking about the choices that parents might face. For genetic enhancement to change human nature or to lead to a post human future, not a few, but billions of people would have to answer yes to this question. So to sum up, changing human nature by a voluntary genetic enhancement I would say is not inevitable because the complexity of neural development and the rarity or absence of single genes with large, consistent, beneficial effects, and because of the tradeoff of risks and benefits enhancement that will inevitably be faced by researchers and by parents. The conclusions that I would draw are the following. I am not arguing that genetic enhancement will never happen. If there's anything more foolish than saying that some technological development is inevitable, it's saying that some technological development is impossible. And corresponding to the silly predictions about the inevitable future of domed cities and jet packed commuters, one can find equally silly quotes from people who said things like we will never reach the moon. So it's not that I am arguing that genetic enhancement is impossible. Rather, it's an argument that bioethics policy should acknowledge the frailty of long-term technological predictions which have a very spotty track record at best. The bioethics policy should be based on fact, not fantasy. Both our positive and our negative fantasies are unlikely to come true, and that policies predicated on the inevitability of genetic enhancement should be rethought. I thank you for the opportunity to present these views to the council. CHAIRMAN KASS: Thank you very much. A very crisp, clear and interesting presentation. The floor is open for discussion. Robby George. PROF. GEORGE: Yes. Thank you, Dr. Pinker, for that wonderful presentation. You mentioned at one point the publicity surrounding claims that genes had been identified which operating just on their own have certain determinable effects, like the four IQ points. You yourself are a person who's very much in the public media. One thing that I notice about these sorts of claims is that when they're made, they get an enormous amount of publicity, and when they're withdrawn, you hear about it later, if at all. I didn't know about the four IQ points had been withdrawn. It seems to me that that's an enormous problem on the public education side, and it's not one that we don't face in the bioethics area as well because so much of what needs to be done really does require the public to have a realistic picture of what's going on in the sciences. Do you have any reflections about that? I mean particularly about the question of communicating scientific information that's relevant to bioethical decisions in the public media? DR. PINKER: Yes. It's something I have thought about a great deal. There is an inherent, I think, problem in science journalism, which is that it is journalism, and science doesn't work on the same timetable. It doesn't work on the same kind of database. Editors, not surprisingly, want news. They want to hear about things that have happened yesterday or this morning, and many of the scientific journals go along with this mentality by having embargoes and building suspense on the development, releasing it at a particular time, knowing that it will appear in The New York Times the next day. Science, especially the science of the human mind, which is a fallible, halting, slow process, depends not on individual discoveries which seldom have a huge, long-term impact, but on the accumulation of dozens or hundreds of studies which all point in a given direction or not. The way that I think scientists proceed or ought to proceed is they look at meta- analyses and literature reviews and assessments of a large literature that begin to emerge years after the first discovery. The way that journalism works is reporting individual discoveries, and I think that's a built in bias in science journalism that inevitably lead to the kind of misinformation that you've alluded to. Science journalists are not going to get their stories published if they simply look at -- in large part. There are exceptions -- at, say, a review paper in a review journal that looks at a meta- analysis of ten years of research. I mean, that does happen, but far more often stories that you read about are based on one discovery that was published in Science or Nature or the New England Journal of Medicine the previous day. PROF. GEORGE: Can I follow up, Leon? CHAIRMAN KASS: Go ahead. PROF. GEORGE: On that, yeah, to what extent can responsibility be ascribed to research scientists themselves who are involved in these episodes? Is it simply that they publish their research and then the journalists get hold of it and there it goes, or are there incentives for research scientists to sometimes -- I don't know if perhaps grants or what -- but are there incentives that would lead people perhaps to hype discoveries that aren't really verified? DR. PINKER: No, there is certainly that, and it would be highly misleading of me to say that this is a problem that comes from science journalism because clearly it's also part of the incentive structure among the scientists themselves. That's absolutely true. CHAIRMAN KASS: Alfonso. PROF. BLACKBURN: I just had one word. It's called "ego," Robby. (Laughter.) PROF. GEORGE: We have that in the humanities and social sciences as well. CHAIRMAN KASS: Alfonso Gómez-Lobo, please. DR. GÓMEZ-LOBO: This was a very clear and persuasive presentation. I think I've persuaded myself that I'm not going to see genetically modified babies or designer babies at least in my immediate family in a short time. But I'm really wondering, what is the notion of human nature with which you're operating here? Because, of course, the expression has represented many different concepts in history, and some of the traits that apparently could be modified, I mean, if we knew more about genes, et cetera, would be considered not really essential to human beings. It would be considered accidental. You know, human nature would not be changed if we are a couple of inches taller or something like that. So I'm curious about that because, of course, in the writings that you gave us, again, the argument is very convincing, but part of it it's because at least to me it's unclear exactly what you mean by human nature as such. DR. PINKER: Yes, that's a completely legitimate question. I would characterize human nature as a set of emotions, motives, and cognitive abilities shared throughout the species by all neurologically normal individuals with quantitative variation, but much less qualitative variation across individuals. To be concrete, every neurologically normal child learns a language upon exposure to it, but we also know that vocabulary size and verbal fluency vary quantitatively along a Bell curve across individuals. Also, an important addendum to that is that what is universal in human nature is certainly not a set of behaviors because we know from National Geographic and Anthropology 101 that there's enormous variation from culture to culture in sexuality, in child rearing and religion and virtually every other trait. And we know that those differences don't come from genetic differences among peoples because of the experiment known as immigration; that a child coming from one culture to another will pretty much or entirely show no genetic carryovers from the culture in which his ancestors belonged. So whatever human nature consists of would be abstract abilities or motives that would translate themselves into actual behavior in radically different ways depending on the environment and the social circumstances. Again, to come back to language as a touchstone, children clearly aren't born with genes for English or Swahili or Japanese. They conceivably could be born with genes that predispose them to acquiring words with a sound meaning pairing, phrases with subjects and objects and nouns and verbs. The abstract universal grammar that my colleague Noam Chomsky made famous, which doesn't correspond to any language that you actually use. Similarly, in the domains of the emotions and motives, there isn't any particular behavior that is universal. It's not the case that, for example, men are universally polygamous polygynous or monogamous. That varies among individuals and among cultures. Nonetheless, it may be true that the underlying desires are much more universal than the overt behavior. We all remember President Carter who committed adultery in he heart many times. As far as we know, he didn't commit it in reality even once. This is, I think, a feature of psychology, namely, fantasy that may be much more uniform that actual behavior. So human nature can't be equated with human behavior. It refers to desires, tendencies, abstract abilities rather than to concrete acts. CHAIRMAN KASS: Alfonso, please. DR. GÓMEZ-LOBO: A quick question. Couldn't we then characterize human nature as a set of capabilities, abilities, potentialities? Since they can be realized in such different ways, one could say there's a potentiality for learning the language and for learning abstract predicates. Now, whether they're expressed in Spanish or in English would really depend on the culture, but then my question would be: what stage of development do human beings have that human nature? DR. PINKER: I'm sorry. At what stage of development, do you mean in the ontogeny of the individual, that is, childhood, or do you mean in cultural evolution and history? DR. GÓMEZ-LOBO: No, I mean in the individual because that's what's been and will continue to be a matter of dispute. DR. PINKER: Well, the answer will be different for different aspects of our psychology. Research on the minds of infants have shown that infants show many more human specific commutabilities that we formerly appreciated. The whole idea of babies was that the world of the infant was a blooming, buzzing confusion, a famous phrase from Williams James; that a newborn basically saw the world as a kaleidoscope of fluctuating pixels and had to learn even that there was such a thing as an object. More recently clever techniques has shown that there are some, many abilities that seem to come on line very, very early in life. Children from the day they're born lock onto human faces. They recognize the sound of their mother's voice, the smell of their mother. As soon as their visual systems are mature, they pay attention to objects, expect them not to disappear without a trace, pay attention to humans and their interactions, pay attention to speech, and so on. So even though there's an enormous amount of learning that takes place, the learning abilities themselves seem to be up and running quite early in development. CHAIRMAN KASS: Gil Meilaender. PROF. MEILAENDER: Let's say that we're persuaded that the kind of enhancement that you were talking about is certainly not inevitable and maybe just not going to happen because it turns out to be very complicated and difficult in the variety of ways that you demonstrated. What do we conclude from that about proceeding with the project? In other words, is there some reason one ought not try it? And one possible reason, for instance, would be that maybe it will just be a lot of wasted effort. On the other hand, I could just say I see all of the obstacles there, but, boy, this would be wonderful if we could do it, and I'd like to, you know, take my shot at it, or is there some other reason? In other words, what do we conclude from this depiction of human nature about the project of human enhancement? Is there any reason not to try it from what you've told us? DR. PINKER: Certainly there's no reason not to have a better understanding of the genetics of personality and intellect and the process of neural development. I consider that to be possibly the great frontier of science in the 20th century. How a one dimensional genome results in an organ like the brain with the ability to see and think and feel and plan has got to be the most exciting and the most challenging scientific question facing us, perhaps the most exciting scientific question of all time. We want to learn more about it. There will be practical applications above and beyond enhancement. For example, if we knew the genetic basis of disorders like schizophrenia, we would know more about the actual molecular pathway from gene to brain to behavior, offering the possibility of non-genetic enhancement, such as drugs that could interfere with the process that leads to schizophrenia. Also, to answer the intellectual puzzle of what makes us what we are. The more detail in which we know it, I think the more enriched we will be as a scientific community and as a species. In terms of actual enhancement, I think the main ethical impediment is going to be the possibility of harm to the unborn child. For as long as that is a considerable possibility, as long as the chances are well above zero that a child could be harmed by genetic enhancement, I think most other questions will remain moot. My hunch is that that's going to be the biggest impediment to getting there from here. PROF. MEILAENDER: But assume that the harm issue were somehow put aside, just for the sake of argument. Would you then have any hesitation about that kind of endeavor? DR. PINKER: If it way, say, one of the you can't be too rich or too thin traits like IQ; I mean, if there were a magic gene that was guaranteed to have no side effects, that could make children smarter, then I would say it's an extreme hypothetical. I would say if that existed, then I would not have any problems with it, but I want to make it clear that that ethical sentiment of mine is separate from the factual arguments that I've been making so far. I have not heard any good arguments, arguments that I consider sound, that this would be a bad thing if we would ever reach that state. CHAIRMAN KASS: Bill Hurlbut, Rebecca. DR. HURLBUT: So I welcome your statements about the difficulty of genetic engineering, but what I want to ask you is assume that genomics will give us a great deal of information about the construction of the organism and, therefore, a lot of power to understand proteomics and, therefore, to intervene with designer drugs at various states. Is it your sense that human nature may be amenable to some kind of improvement by alteration through pharmaceutical agents which would not be as dangerous? And specifically, I want to ask you: do you think that we might make moral improvements? And a corollary question is: do you think that there are genetic and, therefore, biochemical differences in human moral nature? DR. PINKER: Okay. Several questions. It might be possible to have pharmaceutical interventions that have a consistent beneficial effect, although, again, there I would urge people to have a skeptical eye on such claims. We now know that the effects of Prozac, for example, are real, but were certainly over- hyped from the way they were portrayed ten or 12 years ago. Just to give one example of how most things will have costs as well as benefits, Prozac in many cases diminishes libido. So should we put it in the drinking water? Would people take it on, you know, a prophylactic basis to feel better about themselves if they knew it would nullify their sex drive? DR. HURLBUT: Is that a moral improvement, by the way? (Laughter.) DR. PINKER: Morally, the question of whether we should eliminate all of the rough spots and pain of the human condition, the depression, the anxiety and so on, I'll give you an analogy of physical pain. There is a syndrome studied by one of my undergraduate teachers, Ronald Melzack, in which some people are born without the ability to feel pain, and first you might think, "Wow, what a great thing. You know, you'd stub your toe and you'd walk away without, you know, swearing and feeling the agony and so on." In fact, this is a bad thing. The people with that syndrome generally die in their early 20s. The reason is that they don't have the feedback signals that tell them when they're damaging their body, and they suffer from massive inflammation of the joints simply from not shifting their weight when it gets uncomfortable, something that's second nature to the rest of us that feel pain. That is going to be true of many of the negative psychological emotions that we feel. The ability to feel sad is the other side of the coin of the ability to feel love and commitment. If you didn't feel sad when you child died, could you have really loved your child? If you can't feel anxious, I'm sure I don't have to remind anyone in this room that anxiety gets us to do many things that otherwise we would not have done. On the other hand, getting back to the touchstone of pain, it's also not the case that if you have a toothache you should stay off the aspirin because pain is a good thing. Pain, like negative psychological emotions is a mechanism that has a function. On the other hand, it's in many cases a clumsy, over- reactive mechanism, and once we recognize what these negative emotions ought to be doing in order for us to lead better lives, there's no reason, I think, for people to suffer simply because on average in the species, the mechanism is there for a purpose. So I don't think there would be a sound argument for preventing people who are depressed or anxious or irritable or hyperactive from doing something that would lead to an increase in their well-being simply because it's unnatural or because the mechanism had a function, as long as we realize that reducing these negative emotions to zero, as with reducing pain to zero, would not be a good thing either. DR. HURLBUT: Can I follow up on that? If there are values to pain, probably there are differences in pain thresholds between individuals. Now, translate that into moral instincts, moral awareness, moral sentiments. Is it in your thought possible that not only do human beings individually vary one to one, but the different small environments of evolutionary adaptation that have produced externally evident morphological differences between human groups' geographic origins might also correlate with differences in moral understanding? DR. PINKER: Well, let me first answer a slightly different question where I think we know more, and that is differences among individuals within a racial group. That is, you take two Caucasians. There is good reason to believe that some moral traits have a partly heritable basis. There's good reason to believe, for example, that psychopathy, which comprises callousness to people and inability to empathize, has a partial genetic basis like all psychological traits. It's only statistical, not absolute. So the answer to the question of could there be variation in moral sentiments, I think the answer is very likely that there is among individuals within an ethnic or racial group. Whether ethnic or racial groups on average differ in moral sentiments is, I don't have to remind you, a politically fraught question. I would say at present there's no reason to believe that such differences exist. It doesn't mean that they can't exist in principle. It means there are no data at present that would lead one to conclude that they exist, and it's a separate question from whether individuals within a group differ. We know just from genetic variation that there are far more genetic differences between two individuals within an ethnic group than there are between the average of one ethnic group and the average of another ethnic group by a very large factor, a factor of at least ten. CHAIRMAN KASS: Rebecca Dresser. PROF. DRESSER: Two questions. I wonder if you have the same skepticism about the ability to enhance physical characteristics in, you know, embryos. And the other, do you think there's something in human nature that makes people want to change human nature? I get very frustrated with this hype because I am somewhat skeptical, but why do the newspapers carry all of this? And why is there this ongoing fascination? DR. PINKER: Yes, yes. Well, for physical enhancement it will, I think -- it won't be as easy, again, as many of the pronouncements in the press would lead you to believe. Remember during the energy crisis in the 1970s you'd often see the ad for the 200 mile per gallon carburetor where you just unscrew your old carburetor, put in the new carburetor, and you would go from 20 miles a gallon to 200 miles per gallon. Now, there's reason to be skeptical of that invention simply because a car engine is such a complex system, and there's such incentives to making it better that if that were physically possible it would have been thought of a long time ago. Likewise with the human body, natural selection tends towards optima. We know that there are tradeoffs in the design of the human body, a simple example being the fact that males are on average physically stronger and faster than females, but also die younger, and those are probably related, namely, that there are different points along a tradeoff. I suspect there is a possibility, having said that, of many genes with very small effects that conceivably could add up to improvement simply because we know that there are differences among individuals. I think that it's much more likely for simple one dimensional traits like height or muscle mass than for a complex system, such as functioning of the heart, which probably depend on combinations of hundreds or thousands of genes as opposed to something like height, which is a one dimensional trait that could be under the control of a small number of them. In terms of the second question, I guess I don't know enough intellectual history to know whether this is really a feature of human nature or whether it's a sort of post enlightenment, Western concept and whether fatalism, you know, there's nothing new under the sun; empires rise, empires fall; time is a cycle, and so on, which of these is more dominant in the history of human thought. It certainly is a feature of our culture to believe that we can change anything we don't like. CHAIRMAN KASS: Mike Gazzaniga. DR. GAZZANIGA: Steve, sometimes there's the feeling that ethicists are chasing rainbows that are generated by the popular press, is one way of saying what you've been saying. If were to just ask you freshly, with you view of the nature of human nature and with the technological advances in neuroscience and biology that are now occurring, what would you see as the great ethical questions of the next 20 or 30 years? DR. PINKER: I would say that one of them was just raised, namely, as we know more about effects of genes on personality and behavior, I think we will have the possibility to answer questions, such as on average do different ethnic groups differ in distributions of genes that have effects on psychology. Should our attitude be don't go there because no good can come from studying these differences? The reaction to the book, The Bell Curve, that came out ten years ago would suggest that by and large we're not ready for such discoveries. On the other hand, is more knowledge always a good thing? And could it be inevitable that such discoveries will arise as a byproduct of ethnic and racial differences in medical treatment? For example, if there are average racial differences in the effects of or abundance of testosterone, a fact that we may need to know in order to study the demographics and treatment of prostate cancer, for example, well, testosterone also has an effect on behavior. What will we do with the discovery of differences if such discoveries are in the cards? I consider that to be a potentially inflammatory area of research, certainly ethically fraught, and I can't say that I'm certain where I stand on that issue. I think drugs such as Ritalin, which would be given to certain segments of the population but not others, will certainly raise issues of equity, who has access to them, and the flip side of that, the allaying fears that they will be used as a method of social control of sapping boyhood, of sedating disaffected inner city youth, all of the issues that have come up with connection with Ritalin may come up with other drugs. The question of moral responsibility in the criminal justice system, in general people who commit heinous crimes must have something different in their brains from people who wouldn't. Otherwise they wouldn't have committed those crimes. We're going to be better and better able to discover them whether there are differences in genes or differences in cerebral metabolism or brain anatomy. I think we'll need to have very clear guidelines for insanity defenses, diminished capacity, and that whole suite of legal issues as we reach the point where for a large percentage of malefactors we'll be able to say this is what's different about them compared to you and me. So those would be three. CHAIRMAN KASS: Could I follow up on this because I was also in the queue? I mean, the subject on which you were invited to speak is massive, and you've chosen in the formal part of the presentation to speak about human nature vis-a-vis possibilities for genetic alteration of it, and let's set that aside. I, for one, don't have any reason to dissent from the presentation. But I guess three things. One has to do with the question of human self-understanding through the progress of, on the one hand, genetics and, on the other hand, neuroscience. In this last remark about moral responsibility and culpability, would you speculate on how an increasingly biologically based account of who we are, whether it be in terms of genes or be in terms of brains, is going to affect how human beings understand who and what they are, that is to say what their human nature is? I think this is partly not unrelated to where Alfonso was going earlier and where you yourself have also, I think, written. Let me leave it at that. I've got a couple more, but let's start with that one. DR. PINKER: Yeah. CHAIRMAN KASS: I mean simply on the question of freedom and responsibility or the character and object of desire, things of that sort. DR. PINKER: Yeah. There certainly will be changes. The idea of humans as possessing some immaterial essence that categorically distinguishes them from animals, I think, is going to come under -- is going to become less and less credible, and there will be, I think, a crisis among the religious faiths that depend critically on the assumption that there is some nonmaterial essence. I mean, this is intellectual development that certainly began, well, probably began hundreds of years ago, but was acute, for example, in the writings of Dostoyevsky and other 19th Century authors. I think there's going to be a rethinking of ethical issues, such as responsibility and justice and equality, not that it will evaporate, not that Nietzschean fear that we'll have a total eclipse of all human values once people realize that the human mind is a product of the brain, which in turn is shaped by genetics. It's not that our values will go out the window. On the contrary, I think they will focus our ethical discussions on what we most value, what we want moral guidelines to do. Let me be concrete because I was very abstract. In the case of moral responsibility, there is the ancient antimony between free will and determinism that has kept philosophers employed for millennia. It keeps college students debating until the wee hours of the morning in their dorm rooms. I think there's actually a more useful and practical way of couching that issue, namely, once we find that the mass murderer has a defect, we find a red pixel in his brain, should we get him off the hook? The practical question is: what are the effects going to be of our policies for holding people responsible? Holding people responsible is basically a long-term deterrence policy. If you hold people responsible, that in itself is an environmental cause of behavior that we hope and, indeed, diminishes the probability of harmful behavior occurring. If someone thinks that they will be thrown in jail for holding up the liquor store, they'll be less likely to hold up the liquor store. The question is: in adopting policies of that sort, which of those policies will have the predictable effect of reducing harmful behavior without causing unnecessary, spiteful punishment of people who could not have been deterred to start with? The reason we don't throw five year olds in jail is that we think that a policy of throwing five year olds in jail will have no effect on the future behavior of five year olds. That's also why we don't punish animals or put them in jail or try to shame them. It would be futile to expect that that will lead to a change in behavior. Whereas for the vast majority of adults, saying that we will hold you responsible we expect will decrease the probability of harmful behavior. Most questions on insanity defense, diminished capacity, and so on, I think, are more fruitfully reconceptualized not in terms of the metaphysical concept of free will, namely, was the behavior caused or not in some metaphysical sense, which is probably unanswerable, but rather what are going to be the effects of those policies. If we had a schizophrenic with a certain brain condition, would not have been deterred from committing harmful act regardless of the punishment that we put into effect, then subjecting him to criminal punishment would simply be inflicting harm without satisfying the goal of reducing harmful behavior. I think that's an example of how a pressing ethical issue will be reconceptualized by realizing that behavior is caused by the brain rather than it simply being eliminated as some people fear. PROF. MEILAENDER: The most effective way of stopping certain behavior would be periodically to frame certain people for having done it and punish them publicly, if we could somehow satisfy ourselves that that would be the most effective way of stopping it, would that be the right thing to do? DR. PINKER: No, because I think the -- PROF. MEILAENDER: But then you think that issues of dessert somehow enter in? DR. PINKER: Yes. PROF. MEILAENDER: And responsibility? DR. PINKER: Yes. I think that the policies in the criminal justice system trade off between having a deterrent structure that reduces harmful behavior while causing the least amount of preventable harm or suffering. PROF. MEILAENDER: But while also punishing only people who are somehow responsible and guilty? DR. PINKER: Yes. And I actually think that the concept of dessert, in addition to the concept of deterrence, they're not -- I don't think they're completely independent because if you probe, if you try to dissect our intuitions about just desserts, they very often, in fact, perhaps even always, act as a kind of long term deterrent policy aimed, I think, at preventing people from gaining the system by acting in just the way that would allow them to escape the net of criminal punishment. Let me be concrete. Why do we track down elderly Nazis in Paraguay even though the chances of them perpetrating another Holocaust is zero? There's no deterrent effect of that policy. Nonetheless, most of us believe that this is the right thing to do, that it's inherently unjust to let them die in their beds without facing justice. Well, in part, it's that even if it has no deterrent, specific deterrent effect on that individual, it would have a general deterrent effect in that future perpetrators of atrocities would have to think twice if there was such an implacable desire for justice, for hunting down malefactors; that even if it wouldn't be worth the while of a society to track them down for that particular case, the concept of just desserts would force potential malefactors from thinking twice knowing that there is this desire on the part of society at large to track them down. And the concept of just desserts, even though there are thought experiments that one could come up with that would pit it against deterrence in specific cases, I think, has the effect of implementing a cheater proof policy of deterrence in general over the long run. PROF. MEILAENDER: Once more, but our motive for tracking them down is in order to deter the future evil doers. There's a kind of a gap that grows up between this implacable desire for justice that we want some people to believe is important and the motivate that spurs us to track them down, which is not an implacable desire for justice and the thought that we should catch them and punish them if we can, but rather simply that if we don't do this, future generations will not be deterred from similar horrific acts. Do I have you right? If so, I think there's a real theoretical problem. DR. PINKER: I would add the proviso that there's a bit of a paradox here, but the fact that we have this almost irreducible, implacable desire for justice itself serves over the long run as a deterrent, namely, if we have an implacable desire to bring people to justice no matter how much it costs, no matter how trivial the gains in deterrence, that itself makes the credibility of the implicit deterrent that much stronger. So there is an autonomous, I think, moral and psychological imperative to see justice done. I don't believe that people literally calculate the deterrent value of pursuing justice, but paradoxically it is that irreducible desire for justice that over the long run makes it effective for the same reason that someone who issues any kind of threat is that much more credible if he has implacable, rational reasons for carrying out the threat. That makes it much harder to call his bluff. And a society or a criminal justice system with the concept of just desserts is harder to -- it's harder to call its bluff or to game the system. PROF. MEILAENDER: Of course, I don't doubt that they're connected in that way, that a system in which justice is rendered will have deterrent effects. The question is: what's first order and second order here? The question is: what are motivations for tracking down that Nazi in Argentina is? And I would have thought that our motivation for tracking him down is, our first order of motivation, is that he's an evildoer and justice requires that we punish him if we can. Our first order of motivation is not that we should track him down so that future generations may be deterred. DR. PINKER: I think the first makes the second more likely, that is, it's the very autonomy of our intuitions of justice that also make it effective as a deterrent. So I think I agree that they're conceptually separate, but I think that they are also ultimately related. DR. KRAUTHAMMER: But are they fictional? PROF. SANDEL: They're an illusion, and in fact, if they heard your analysis, they wouldn't be so implacable. They'd just be free riders and justice could fall pray to a collective action problem. They think they're implacable because they're under the illusion that they're trying to get this old Nazi because he ought to be punished because he deserves punishment. And you then describe, well, that's actually a functional illusion that gives the implacable character to their pursuit and that has these desirable things in the long run. But if they heard and grasped the truth that you're offering, then they would be rid of their illusion. The guilty deserve punishment, and therefore, they should go running after him, right? DR. PINKER: Well, not necessarily because the fact that I can explain, say, the ultimate long-term, perhaps even evolutionary rationale for a deep seated intuition, namely, bad people must be punished, doesn't mean that that sentiment is any easier for me to give up. It may be that here's the reason why. PROF. SANDEL: But on reflection it should be given up. DR. PINKER: Well, even if so -- PROF. SANDEL: But shouldn't it? I want to know what you think. Never mind about the whole evolutionary thing. DR. PINKER: Right. On reflection, there are a lot of things that should be given up that we won't give up because of the way we're built, and I think the desire for justice, even if I can tell you why my brain has this concept of just desserts and I can say that in another planet, another evolutionary history my brain may not have had that intuition, the fact is it does have that intuition, and that intuition is -- PROF. SANDEL: But that intuition is so biologically brute that even listening to your deconstruction of it won't disabuse me of it? DR. PINKER: Yes, I think that's right. I'll give you an example. In many -- CHAIRMAN KASS: Also, the existence of your immaterial soul, Michael. Don't worry. DR. PINKER: Well, among the justifications for criminal punishment, one -- of course, opinions vary. Some people do disabuse themselves of intuitions whose rationale are then laid bare, but my understanding is that many judicial theorists say that some degree of retribution is a legitimate function of criminal punishment; that we allow more and more victims of crimes have a say, and that the widespread intuition that somehow the universe is knocked out of balance if evil doers are not punished above and beyond the practical effects is often recognized as a legitimate function simply because we think that it is part of human nature, that people will be enraged, will seek private vengeance unless society satisfies this desire. So I don't think it's that easy to eradicate, and it's probably a good thing that it isn't that easy to eradicate, although it is, I think, a good thing to be aware of it simply because we can then -- to get back to the question that Professor Meilaender raised, if it was only deterrence that we wanted criminal justice to accomplish, then we would do things like frame a few people just to keep everyone else on their toes or many other things that we would find horrific. Realizing what the goals are of a system of deterrence, we can calibrate the desire for deterrence against the other desire not to inflict unnecessary harm, and realize what we're doing when we impose these policies. At least that's what I would argue. CHAIRMAN KASS: Dan Foster. DR. FOSTER: You know, I thought earlier that you really were holding to the conclusion that, you know, once we knew the genes and everything would follow. We'd get to something. But it sound a lot to me like your deep intuition is very much like what somebody else might call an essence, that this desire for justice, let's say, that's so deeply intuitive in you, that you are not sure where it ever came from. And I think that maybe some people might be skeptical about the view that there's really no fundamental difference in the nature of an animal or of a human, since I don't know what the exact difference is between the genes in a chimp and the humans. Maybe five percent. It's pretty low though as far as we can tell. I mean, it's pretty low. But one doesn't, I think, normally sense that a chimpanzee or certainly lower species have an intuitive drive for justice. I mean, G.K. Chesterton used to always say that there were certain fundamental differences between animals and humans, that the human animal, for example, creates. She makes art and music, not nests to live in, and no other animal species as far as we know does that. He said the human animal differs from all other animals in another respect, that they have a deep, intrinsic sense of guilt, that we know intuitively the difference between right and wrong. Now, one would argue, you know, that my dog knows the difference between right and wrong because I've got a Pavlovian response, you know, to him if he doesn't behave. You know, the human intrinsically knows the sense of joy, in a way. Animals don't laugh as far as we know. And finally -- I mean, the hyena might -- but finally, he said that the human animal is very peculiar in that from the beginning, even from the earliest graves that we see, somehow worships, has a sense that there's something that might be intrinsically different from what genes do. I mean, it seems like to me that you've shifted a little bit from your earlier sort of a genetic determinism, if that's not an old fashioned word, to a description of yourself and others that says that there is something different about the essence of this particular species. I don't know whether that's -- but just listening to you. I have a friend at my medical school who won a Nobel Prize in medicine and who happens to be Jewish, and he usually argues very intensely down to the quarks about determinism. And so I didn't say, "Well, it's too bad that Hitler got those bad quarks and genes and so forth and he ought to go free," because it was all determined along those lines. And then immediately he usually sort of backs off. "Well, I didn't really mean it that way." But it sounded to me, and I'd like for you just to comment about that, just to focus on the justice issue here, that you were describing when Michael was pressing you about yourself and not the literature and so forth, that you were saying -- I think I heard you say that there's something deeply intuitive in me that makes me drive for justice, and I want to know what the difference is between your genes and the chimp's genes that give you an intrinsic drive for justice that maybe the chimp has, but I don't know. I mean, I don't know, but at least the studies haven't shown that so far. DR. PINKER: Yeah. Well, the genetic differences between humans and chimps are small as a proportion of the genome calculated on, you know, a base pair by base pair basis, but because DNA is basically a computational system, small differences in the sheer information content can make a big difference in the final product. So just an analogy, if you were to take a text file on your computer and change one bit in every byte, the result wouldn't be 12 percent different. The result would be 100 percent different because a single change can result in a protein product that has a radically different effect. So even though genomically we're very similar to chimps and in terms of the phenotype there are more similarities perhaps than we'd want, including by the way laughter; chimps definitely do laugh, but this is not to deny that there aren't significant differences between humans and chimps, just as there are significant differences in any pair of species. So the analogy that I often use is that an elephant has a trunk which is as far as we know unique among animals. It's the only animal that has a trunk. Humans also have a number of unique traits: language, that is, grammatical combinatorial language; probably moral sentiments, such as guilt, shame, trust. One can debate whether there are rudiments of them in chimps, but there's no denying that what you find in humans is very, very different from what you see in any other primate. I don't consider this to be an evolutionary paradox for the same reason that I don't think that the fact that the elephant has a trunk and its relatives don't is a paradox, namely, that evolution creates divergence. It can lead to the development of traits, including mental traits that are found in one species but not its relatives, and I think there are quite intelligible reasons for thinking that in the case of the evolution of homo sapiens things like language and the moral sentiments and technological know-how, such as tool making, developed in the last six to eight million years in a much greater extent in our branch of the family tree than in chimps. And I think that the sense of some kind of primitive sense of justice, of just desserts, might be something that really is universal in humans and probably absent or rudimentary in chimpanzees, as you said. DR. FOSTER: Thank you very much. We'll be talking all night if we continue this. So I yield in response. CHAIRMAN KASS: He's got the best subject in the world. DR. MAY: It may be the same point that Dan was interested in, but it seems to me finally you have to say that Eichmann is a victim for the larger social good served by punishment even though biologically considered he doesn't deserve it. In that sense we have framed him, but for a good purpose. DR. PINKER: Well, there's a lot of debate on the specifics of the Eichmann case, namely, whether he really was the faceless bureaucrat that he conveniently portrayed himself to be. PROF. SANDEL: That would make no difference to this question. That would be irrelevant to this question DR. PINKER: Well, the way I would try to make that question tractable is if we have consistent policy for what to do with Eichmanns and we held to it steadfastly and it was announced beforehand, what would be the effect on future Eichmanns? That's not identical to the question that you raised, but I think it's more tractable than the question that you raised, and I think my hunch is that if you actually worked it out, you would end up in a very similar position as the one that you would arrive at if you reasoned in terms of the raw intuition of just desserts. I think that the intuition of just desserts, no matter how passionately held, can be examined. We can say, "Well, let's lay out the thought experiments. What would you think if?" And my sense is that it would be a -- in the cases that I've thought through, such as insanity defense, punishment of animals and children and the brain damaged and so on, you end up with very similar answers to the one of what's the best long-term general deterrence policy balanced against the moral harm of inflicting suffering that has no beneficial -- PROF. SANDEL: Does that mean you agree with Bill's premise that on your account, every instance of punishment is a case of framing? DR. PINKER: No, I don't. No. PROF. SANDEL: Some are and some aren't? DR. PINKER: Well, in an ideal system none of them would be in the sense that we would not inflict punishment on someone that we had excellent reason to believe did not commit the act and hence could not have been deterred by such a policy in the future, namely, innocent people who are frame. There are other people in those shoes out there, and a policy that would net them in isn't going to prevent them from doing evil because they didn't do evil and they never wanted to do evil, and so that would be a moral harm inflicting unnecessary suffering. So that's why we -- PROF. SANDEL: That would all depend on the perceptions and beliefs of the onlookers. It would have nothing to do with the guilt or innocence of the person. CHAIRMAN KASS: But, Michael, you -- DR. PINKER: I'm not sure I follow that because if the person didn't commit the harmful act and would have no impact -- PROF. SANDEL: But everybody else believed they did, then for long-term deterrence reasons you do want to punish that person. DR. PINKER: Well, if long-term deterrence was your only goal in the criminal justice system. If you had two goals, namely, long-term deterrence and prevention of unnecessary suffering, then you have the tradeoff of under what conditions will you tolerate unnecessary suffering in order to get an increment in deterrence. And I believe that in the case of deliberately framing an innocent suspect we would say that the first outweighs the second. PROF. SANDEL: It depends what the consequences would be. There's the famous hypothetical of a heinous crime that's been committed. The entire town is outraged. They're about to go on a rampage against the neighborhood from where they think the criminal came. The sheriff doesn't know who committed the crime, but to prevent this terrible cost and rampage goes and takes the town drunk from jail, announces that he's the criminal and hangs him. DR. PINKER: Yes. That would be the utilitarian calculus of preventing the -- and your question is why? I mean, I assume that the assumption is that we all consider that to be a bad thing to do, and the question is why. Is that what you're asking? PROF. SANDEL: Yeah. DR. PINKER: It's a good question. I would concede that it's the weak point of this analysis, and I haven't thought that case through in enough detail to answer you, but I suspect it would be state that as a policy, and that is not just what does the sheriff do on the spur of the moment, but you write it down. What should sheriffs do in general? What should law enforcement officers do in general? Look at the policy and see how much unnecessary suffering does it cause as opposed to the alternatives. I'm not going to bluff and say that it will come out the same way, but I have a hunch that it would. But granted it's a valid objection. CHAIRMAN KASS: Paul McHugh. DR. McHUGH: I enjoyed your talk very much, and the theme of your talk was that things were more complicated than we thought and interfering with things at the genetic level and at the neuronal level was going to be less likely to produce a better world and a better person than we imagined. This same kind of thing is turning up here. It seems to me when I hear you discussing with Michael and Dan and others, you seem to function on the idea that things work in an A to B position. We do things because we know the consequences, and that you and our understanding of human nature might be able to recognize those consequences. But it seems to leave out what Charles Saunders Peirce used to talk about thirdness, what the symbol of all of this is, and that human beings have a capability, therefore, of seeing something and having it have a deep and penetrating meaning to them that they ultimately make more and more explicit as they become more and more developed. And so, for example, in this area of punishment, you talk about deterrence and you talk about retribution. I've always thought about it in reprobative terms rather than retributive terms, that is, this act we cannot tolerate amongst human beings, not as to whether there's going to be any more of them or not, but really because what it means. And we see that punishment work in a good way and a bad way in relationship to notorious cases. I feel that the execution of Eichmann was very just, very true, and if I could have been one of the guys tracking him down, I would have loved it. I would carry it as a badge. But, you know, the execution of the Rosenbergs was thought in some way to perhaps be going to deter. It didn't deter anybody, and in fact, we now know that, in fact, there was a very cruel and vicious element to putting the Rosenbergs to that test, that the government probably thought that they would crack them rather than have them die. So those two things are events in which punishment was delivered. One of them -- both of them might have been thought of as having rebributive elements, but reprobatively they are miles apart. So my question to you fundamentally is this. Do you not give to human nature the capacity to move from their implicit things, to make things progressively more explicit, and in the process progress not simply in the direction of being more effective, but also to being more good? DR. PINKER: Oh, absolutely, and if I've tried in my own writing to change the common conception of human nature, it would be to emphasize that one of the features of human nature is a combinatorial apparatus that can generate new combinations of ideas, and again, I'll use language as my touchstone. We're equipped not with a finite list of sentences that like, you know, a Sesame Street doll where you punch a button and one of a dozen sentences is selected at random and comes out verbatim. What we're equipped with is a set of grammatical rules that are assembled, nouns and verbs in new combinations that allow us to express new thoughts. Similarly, in thought, which obviously feeds language, we have the ability to multiply a fixed stock of ideas to come up with unlimited combinations. We can have theories of the origin of the universe. We can have new political theories. That's why we're in the business that we're in of exploring ideas and making discoveries. So they bear the stamp, I would say, of particularly human ways of thinking. We conceive of things in particular ways that a Martian might not. On the other hand, that doesn't mean that there's a finite number of human-to- think- about thoughts or that we're doomed by our neurology to recycle the same ideas over and over again for the same reason we're not doomed to regurgitate the same sentences over and over again. DR. McHUGH: So you would, therefore, agree that there might be determinism, but you don't believe in fatalism. Would that be a useful way of describing yourself? DR. PINKER: I don't believe in determinism. I mean, determinism is a word that has many meanings, and it's often used more as an epithet, I think, than to -- I mean, I don't know of anyone who claims to be a determinist. I know a lot of people who are called determinists. If you use determinism in the mathematician sense of an event happening with Probability 1, then I am absolutely not a determinist and not for any philosophical reasons, but for an empirical reason. The identical twins raised together correlate only, say, .4 to .8. That technically refutes determinism in its actual sense, but I certainly do believe that the genome leads humans to think and feel in characteristic ways, but because the brain is so complex, because it has multiple systems and a number of them have the ability to crank out new combinations, infinite combinations of ideas, the idea of a fixed human nature doesn't mean that there's a fixed repertoire of behavior or thoughts. And I think we have the ability to, well, I'd like to think and I think we do have the ability to learn the lessons of history, to be persuaded by argumentation to see things in new ways, and in fact, again, this isn't just kind of a sappy sentiment, but things have changed which would be impossible if we were genetically fixed. The rates of violence have gone down in the last couple of hundred years in the society. Concepts that were thought to be inevitable, such as slavery, subjugation of women, inevitability of blood feuds, for example, all have greatly diminished. So the notion of human nature doesn't mean that society will never change or ideas will never change. DR. KRAUTHAMMER: Can I come in here a second? CHAIRMAN KASS: Go ahead, Charles. DR. KRAUTHAMMER: But what I hear is a critique of determinism on the basis that the old determinism was very one to one and very unsophisticated. It's interesting we are not discussing here bioethics but the rather interesting world of evolutionary psychology, and I think that's what some of us are rather seized by in this discussion and provoked by. You said a little earlier that you thought one of the challenges or one of the developments in the future is going to be a decrease in what I believe you called essentialism, a self-perception by human of their exceptional nature. If you take away that essentialism, then you end up with either the theory of justice, for example, that is based entirely on its evolutionary advantages, meaning deterring bad effects and bad behavior, and leaves no space for anything else other than illusions. So my question is that if you believe in evolutionary psychology, biology as an explanation for our current human nature and you believe that it really excludes any essentialism, which is some sort of archaic, perhaps superstitious notion about human nature, then what's left? And what I hear is what's left is a notion of criminal justice, for example, that leaves no room whatsoever for the notion of real guilt, of real agency, and that's what I think we find rather shocking. Am I correctly explaining your understanding of nonessentialism? DR. PINKER: Yes and no. This is what I call the fear of nihilism, that a materialist, Darwinist view of human mind will expose all of our values to be in some sense shams, that they are just means to the end of some practical function, like propagating genes, deterring violence and so on. DR. KRAUTHAMMER: Well, you gave us a pretty good example of that with criminal justice. DR. PINKER: Yes. Well, let me give two answers to that. One of them is this is what Daniel Dennett calls the idea of Darwinism, is universal asset. It just eats through any possible container and dissolves everything we hold precious. First of all, the fact that we can understand our own sentiments doesn't mean that they're shams simply because they are our sentiments. So let me give you an example. There's reason to believe that our aesthetic judgments are evolutionary adaptations. We like particular landscapes, particular faces because there are rational reasons why we should have evolved in that way. Does that mean that nothing is beautiful and that there's no point in looking at attractive landscapes or faces? Well, no, because that is the way we're put together. The fact that we understand why we're put together that way doesn't mean that here in our own skin those sentiments are any less real to us. If cosmically you can say there's nothing particularly beautiful about the Rocky Mountains as opposed to a New Jersey oil refinery, I don't know how to answer that question, and I don't really care about that question. The mere fact that I am wired together, wired to like the Rocky Mountains better is good enough reason to indulge that. Also, there are some cases in which I think we can actually step outside our skin and at least entertain the possibility that some of our perceptions and values do pick up on an external abstract reality. Again, I'll be concrete and I'll give an example. There's good reason to think that our sense of number is an evolutionary adaptation, that there's good reason for an organism to be able to tell the difference between one and two and three and have the elementary concept of addition, but it doesn't mean that one and one equals two is a hallucination or a fiction. It's in the nature of reality that any organism that can grasp the concept of number is forced to come up with certain conclusions. Likewise there are cases in ethics, at least so some moral philosophers argue, and I'm not prepared to disagree, where there is a reality to some moral judgments, and the fact that our moral sense may be an evolutionary adaptation of the brain doesn't mean that the things that it thinks about are figments. DR. KRAUTHAMMER: All right. Let me test you on that. If you say evolution urges or -- I'm sorry. CHAIRMAN KASS: No, go ahead. One last round because we're well over. DR. KRAUTHAMMER: I'm sorry. It's been advantageous for us to understand that one and one is two, and that is giving us an intuition into a platonic universe in which one and one, in fact, are two, and we understand that. So by analogy, evolution has given us the intuition that we ought to hunt down a Nazi. Does that give us any intuition or does it not give us the intuition that there's a platonic universe in which that Nazi is evil and ought to be hanged regardless? DR. PINKER: Well, let me put it maybe. Let me put it that way. It's not a question that I can answer that has, you know, challenged the best minds for millennia. The way I would put it is there are certain core moral intuitions that I think could be argued to have a basis in reality, such as the fact that no particular person can argue that he occupies a privileged position in the universe whose well-being can trump the well-being of anyone else simply because that's a logically untenable argument as soon as one enters into rational discourse at all. For the same reason that I can't say that this spot in the universe is privileged because I happen to be occupying it, I can't say that my interests are privileged over yours as long as I'm willing to enter the discussion at all. That isn't an arbitrary figment, but it's in the nature of that kind of discourse in the same way that one and one equals two is a necessary consequence of thinking mathematically to begin with, which is a reason that I think different moral traditions end up with some notion of reciprocity or golden rule or categorical imperative over and over again. It's a kind of forced move in perhaps a platonic nature of relationships among ideas from which one perhaps could deduce that Nazi war criminals ought to be hanged from a chain of intermediate steps. Given that I don't want to be the victim of genocide, how can I tolerate it if other people are the victims? Then if I want to reduce it over the long run, given the presence of other agents trying to gain the system, what is the most effective way of universalizing my own desires, and so on? I could imagine a chain of steps that would lead to that as a theorem from axioms that might have some kind of universal warrant. So I mean, that's the best that "little me" could do in grappling with these cosmic questions. I don't have an answer to them. I think that we can make progress in scrutinizing them and not prematurely satisfying ourselves that some intuition simply ought to be accepted as the nature of things without penetrating that intuition and asking why might we have it. I think there's only good that can come from scrutinizing those intuitions as opposed to taking them as givens, and the reason that I feel emboldened to say that is that we know that people can have absolute certainty in certain intuitions, which upon reflection they can be argued out of or externally we recognize to be horrendous, such as slavery, ownership of women, other things that seem self-evident in past centuries, but where I think as these things get scrutinized they are revealed to be inconsistent with other beliefs or untenable. Because we know that that kind of moral progress can take place when intuitions are scrutinized, it is important to scrutinize our own intuitions. It doesn't mean that we will end up in a state of nihilism where all morality is a fiction, but I think and hope and would argue that it would lead to a case where our ethical system is more human, more effective, and more defensible. CHAIRMAN KASS: There are lots of people at this table who would be eager to continue this for hours. We're already 15 minutes over, and since I was next in line with a long list, I will squelch myself, express my thanks to you for a very interesting and forthcoming and provocative conversation. We'll have a 15 minute break in which the people who want to sort out the question of whether the differences between Dr. Pinker and the rest of us is owing to the fact that we're just differently wired or he actually has discovered the immaterial truth on this subject. But we'll take a break, and let's make it a little shorter. Five minutes to four so that we won't have to finish too late. Thank you very, very much. (Applause.) (Whereupon, the foregoing matter went off the record at 3:47 p.m. and went back on the record at 4:11 p.m.)
Session 4: Beyond Therapy: Better Memories? CHAIRMAN KASS: The last session today is revisiting on the topic of better memories, the promise and the peril of pharmacological intervention. And we have here a staff background paper which, before taking up the technologies now and perhaps soon to be available to intervene in human memories, talks about what memory is in its heterogeneity, talks a lot about what a better memory might be and how difficult it is to specify that; different ways in which memory fails or fails to please us, grouping them amongst lost memories which might be restored, weak memories which might be enhanced, and then bad memories which one might choose to transform. And that paper concludes by suggesting that perhaps it is this last category, the blunting of the affective aspects of memories of painful, unpleasant memories that might be the technology most upon us. And, in fact, in the session that we had with Dr. McGaugh and Dr. Schachter, there was some discussion about that prospect in the follow-up discussion. And then we have also as background, as I think the point of departure from this discussion, a paper that Gil Meilaender wrote really in response to a request and a conversation that we had after the last meeting, which takes up this last possibility and raises the question as to why should we remember especially those things for which a case might be made that we'd be better off not remembering it. I don't want to have a discussion aimed primarily about any of the papers precisely, and Gil has asked that this not be a sort of back and forth interrogation of what he said, but the paper really is to be used to prompt a discussion aimed at an increased clarification and understanding of the particular issue. And, once again, I'm going to try and this time I hope to produce a question that's less easily discussed and more readily engaged. Let's put it this way. We have, although the obliteration of all pain would produce a kind of bodily disaster, as Professor Pinker already mentioned, but we do have analgesia and for certain kinds of severe infliction of pain, we even have anesthesia, and the question is why shouldn't one think about analgesia for the memory. Why should we have to live with painful, guilty, shame- filled, shocking or unpleasant memories if we don't have to and science could offer us a way out of it? That's a question that Gil offers a kind of argument for, an argument which he can make for himself or we can draw on if we wish, but I think that's the question that the paper is trying to get us to think about, and I would simply like to pose the question flatly and see where we go. Mike. DR. GAZZANIGA: Have you got any Ritalin? (Laughter.) CHAIRMAN KASS: Look. If this -- DR. GAZZANIGA: A fascinating thought. Well, both of these papers are really well done, I thought, and they remind me of Yogi Berra who says it's not what you don't know that hurts you. It's what you know that just ain't true. And what is not brought up in these two papers probably is a product of who we selected to have as our experts when we had our memory experts in. Dan and Jim are fascinated with the encoding part of the memory story, but that's only half of the story. The other half of the story is the recall of information, how you retrieve it, and there's a whole rich literature on that. And basically the point I want to make is that what we know about that is that every time you retrieve the memory and it then becomes relayed down as it were, re-remembered, the memory changes. So it's the memory that you think you have that you are languishing on and that is governing your current beliefs or mental thoughts or what have you, really has been so buffed by you recalling it through the past that if you actually went back to the original event, you many times wouldn't recognize the two. But your current memory of it and the actual event, and for those of us who write scientific review papers, we have this problem all the time. If we fail to go back and look up the source of the paper that we actually are trying to write about in five years, we always get it wrong because the memory, the recall system along with the recoding of the information that's recalled, plays all of these tricks on your mind. So my point is that blunting of the memory, there's a natural blunting of it that occurs just as we recall past events, and it's just a part of the normal process of thinking about the past experience. It's not that there's going to be this bullet of a drug or a pharmaceutical that's going to come in and modify this pristine, clear memory of a particular event. And the only other thought, and I cannot speak for the rest of the afternoon, is in the background paper that touched on memory and aging and memory and loss of memory and so forth and the potential pharmaceutical enhancements that could occur to help our lagging memory system, the one point that's lost is that we all have, all of us in our culture have lost a great skill set in our memory tool box. It used to be that I think we all in this room go back far enough that we used to remember a verse at length and could repeat it and use it constantly. I heard a little bit this morning, and I was very impressed. And we've given that tool box up for the visual culture we live in for all of the pneumonic aids we have all around us. And as a result, we're not going into the aging process particularly well-equipped to continue the mental exercises, and so the deterioration that is occurring through the normal aging process becomes exaggerated because of looking at -- I'm not talking about the people in this room. CHAIRMAN KASS: No, no. DR. GAZZANIGA: But our culture simply is not applying this tool box of rehearsing information or remembering it as they age, and certainly it is clinically known that the people who are insulated the best against early Alzheimer's and all the rest of it are the people who have kept mentally active and are using their memory skill system with vigor. And so therefore, the reason that I'm bringing that up is that it's my bet that a behavioral resurgence of that will probably even in the short- run be more productive in enhancing and protecting us against deteriorating memory than the pharmaceuticals that are imagined and that, in fact, now are being planned by one start-up or another. So those are my observations. CHAIRMAN KASS: Mary Ann. PROF. GLENDON: Can I just try to make a connection between what Michael said and Gil's paper? I think Michael reminds us quite rightly that this business of memory is very tricky, but the thing that I want to -- one of the many things I loved about Gil's paper is the way he connects memory with the narrative of who we are, with the story of who we are. And I was trying to think about this problem of accuracy of memory and connection with that narrative, and here the literary piece that we need to put in our collection is Mario Vargas, "The Storyteller," which is about a tribe that is losing its storytellers, this Machiguenga tribe, calls itself "The People Who Walk," and they tell their stories. They have an official storyteller who tells the story over and over again, but, Michael, every time it's told it's told differently. And the storyteller sometimes says, "Well, when the great god exhaled us, perhaps he did this." And so there's this perhaps that lets you know that the storyteller knows about it. So what's happening is not only remembering, but sort of recreation of the story as it's passed on, and I think the most -- even though the subject here is memory, I think that Gil was right on when he said that what connects this memory question to being human is its connection to our stories about what our life means, the search for meaning. CHAIRMAN KASS: But I mean, let me make life somewhat difficult. I mean, taking from Mike Gazzaniga's comment the suggestion that, well -- I mean, it was quite wonderful. For the problem of bad memories, time is the best remedy since it won't bother you so much as you get older. I wish it were true. There are still things that make me wince. (Laughter.) CHAIRMAN KASS: And the other part of it is memorized poetry, never mind pharmacology, a sentiment which we could endorse for multiple reasons. But it seems to me that if having a narrative is a narrative of one's own life is somehow central to our own humanity and self-understanding, and unless the retellings of it are simply accidental in the way in which the messages and the telephone game get changed inadvertently, it does suggest that one could be an editor of one's own narrative and be increasingly the author of our own life, the way we are at least to some extent. If I don't say it, Bill May is going to say it. It's not simply a matter of acquiescence and taking what comes, but it's a matter of trying to shape and by acts of will form the life story prospectively, and so the question is so why shouldn't one as the partial author, not the exclusive author of one's life, do a little editorial work to take out those things the memory of which will besmirch, upset, trouble, cripple, I mean, fracture a life? Why should the narrative that we tell ourselves be somehow necessarily faithful as much as memory could ever be faithful to what we actually endured? I mean why not be good editors rather than let accident write the story? PROF. SANDEL: Let's see what Gil has to say to that. CHAIRMAN KASS: Huh? PROF. SANDEL: Let's hear what Gil has to say to that. CHAIRMAN KASS: You should make him answer first. PROF. MEILAENDER: That's an excellent idea. I was just going to say why exactly did you want to make this case for living in a world of fantasy. You know, this is Rousseau -- CHAIRMAN KASS: I'm just asking. PROF. MEILAENDER: This is Rousseau walking across Europe preferring to think of kind of the women he can conjure up in his imagination to real women. PROF. SANDEL: No. To tell a life story isn't to be a beat reporter, Gil. That's how I understood Leon's point. PROF. MEILAENDER: No. You asked why should one want to live truthfully. DR. GAZZANIGA: Well, the point is that the truthfulness isn't very good. I mean, but -- PROF. MEILAENDER: But, Leon, I acknowledge that one could strive for it. CHAIRMAN KASS: No, no, no, no. PROF. MEILAENDER: Granting that none of us will remember perfectly, you can still try or you can decide to kind of fix up and get rid of. That was what -- PROF. SANDEL: But now you're suggesting, Gil, that the truest life story, the truest narrative for a person would be a transcript. PROF. MEILAENDER: No, I wasn't. You see, we're into the Q&A again. This is not the right way to do it, and I'm just going to shut up in a minute. The paper acknowledges that we do reconfigure inevitably and that, indeed, one can't necessarily say what the meaning of an event is until it's seen in the context of the whole life. That seems to me to be true, or at any rate I certainly say it in the paper. But simply taking charge of it in such a way as to kind of eliminate those matters that one finds painful in some way doesn't seem to me to be an attempt to live truthfully, and it doesn't take seriously the fact that we don't know what the meaning of those events can become in the course of a whole life as it's lived out. CHAIRMAN KASS: Did you want to follow up that? PROF. SANDEL: Just one follow-up. If we agree that a life story as a narrative is central to the meaning of a life, and I think that point comes out powerfully in your paper, Gil, and Mary Ann elaborated this idea, then we agree that a certain element of creative fashioning is not only desirable. It's essential if the life story is to be other than a stenographic transcript. Now, if that's true, then the next step would be to ask: well, that means being less moved by some facts about our lives than others, seeing them as less central in the story that we weave, and memory enters here because one of the ways in which we de-emphasize certain features of our lives and emphasize others in weaving the story may have to do with a certain faculty not just of will, not just of saying, "Well, let's array all of the facts here truthfully and then I'll pick out the significant ones," but it has to do with the way we take them in in the first place. And memory even untouched by drugs is selective, and the principles of selectivity may have something to do with bias and prejudice, but may also have something to do with the distinctive way we take in the world in the first place unless you think we just take it in as brute sense data. And so that suggests that even without the drugs memory is going to be selective memory, selective in a way that reflects our distinctive take on the world. And so then the objection to altering memory, whether to blot out traumatic memories or to increase our ability to remember certain things on either direction might be seen as part of what we do anyhow when we take in the world, and it might be odd to think that the way we just happen to take in the world unaltered from either direction is the past. We're back to the moral weight of the given. Why should we think that that's necessarily going to lead us to the truest life story? PROF. MEILAENDER: I think it's peculiar to use the word "selective" in connection with sort of just what we take in. We haven't yet gotten to something that deserves the word "selective" at that point. You know, experience comes in. It's organized in various ways. I understand that, but the notion of selecting in any strong sense doesn't fit that. PROF. SANDEL: No, but experience doesn't just come in. That's the point. PROF. MEILAENDER: I said it's organized in certain ways, but the language is "selecting," I think, is not very good language there. PROF. SANDEL: Well, apprehending, and some people are better at apprehending than others, more insightful. They're -- PROF. MEILAENDER: Yes, but that's got nothing to do with their conscious shaping of their sense of the narrative of their life. CHAIRMAN KASS: Bill May. DR. MAY: Interesting to think about imagination in relationship to memory. I mean if we didn't remember the past at all, imagination would function in relationship to the future, but it has very few controls on fantasy. If I didn't know very much about the various inertias at work in my life, I might fantasize all things, and so memory has -- and your discussion of embodiment I think was very important there, Gil. Memory in lots of ways serves to tether, tame, and restrain imagination as it relates to the future. On the other hand, imagination is very important in the functioning of memory because, after all, it's passed and, therefore we have to engage in an act of imaginative retrieval. So it's very interesting. The retrospective of imagination serves in various ways to constrain the prospective side of imagination as we muddle our way through the present moment. Now, you use the word selection. But also there's re-collection, is a very important feature, and when one thinks of the moral task of old age -- I think about it more and more -- as it bears on this whole question of coherence, there's a task of re-collecting one's past if you're going to be concerned at all with the question of coherence and think about life as a narrative. There's a kind of re-collecting that goes on. That word, I recall in root, "collect," "lectionary," and so forth. It's a reading. It isn't simply a record. It's a reading, and as long as we're alive, there is a rereading that is going on in our relationship to the past. But as you deal now with what you call the wince events, of which they're very important because I discover I am more afflicted by them when something else is going wrong. So they become symptoms to me when I'm reliving certain kinds of things that, in fact, there are other orders of disarray and incoherence in my present life that makes me think about some of those wince events. I mean, Paul McHugh will know a great deal more about this than I do. But Gil also introduces an interesting issue. How do you relate to those very painful experiences or wince events, and what kind of editing and selecting now, partial reading, where you remove from the book, remove from the pages certain kinds of events to deal with them, and that's one way of achieving a coherence, but it's dealing not with the whole truth. We know that. But Gil, on the basis of his religious background at some point suggests that in this life we never have a vantage point that gives us the whole truth, another way of saying there isn't the -- the final coherence is never ours, and I guess it is what has led religious traditions to talk about the problems of reparation and atonement; that there's a lot in our lives, even when we make the best efforts at retrieval and collection and so forth that are ragged, are frayed, jagged, that do not fit in, and so forth, and we're engaged in unfinished business. And where does the completion come from? And oddly, humility requires us both to aspire for coherence, but to be cautious in assuming that we ever achieve some final vantage point on that, and, of course, that's why we need one another to engage in that kind of correction in our readings, which are so partial, so agenda- driven, so often, from day to day. CHAIRMAN KASS: Does that that sort of large and very moving anthropological account lead you to conclude that we doctors of the soul, that is to say I'm speaking for McHugh, not to come in there and do anesthesia of memory, not even for the most painful of memories, if he could? DR. FOSTER: Well, while he's thinking, I mean -- I mean you all are -- I would myself think that that would be a great loss. You know, I mean, Jacques Martain wrote about this extensively with something that -- I forgot exactly who he was quoting about the memories that come like lightning uninvited in, you know, from the past. If you can allow just a little homely example of this, when I was about 16 years old or 17 years old, 16 years old, I think, I got a very good job working in an electronic -- I was a sort of a jack of all trades there and so forth, and one of the bizarre things, there were two of us working there, and he asked me to come work at his house on Saturday, which was not a day that I worked, and I had a date. So instead of telling him that I had a date and that I didn't think I could come, I made up a frank, bizarre lie. I said that I had a brother who was coming home from the Service and that I had to greet him. (Laughter.) DR. FOSTER: So my friend went out to work with him, and my boss, who was a wonderful boss, said, "Well, Dan couldn't come because his brother's coming from the Service," and whereupon my friend, Fred Kongabel, says, "Well, he doesn't have any brother in the service. (Laughter.) DR. FOSTER: Right? Well, so the next day, and to his credit, my boss, who was a wonderful person, confronted me with this and in a reparative way. I thought he would fire me, but he said, "I was very disappointed that you simply didn't tell me the truth because I would have understood. I've had dates before." Well, to this day, that is one of the most painful memories that I've ever -- I mean, it doesn't sound like much, you know. It was just a little white lie because I didn't want to work on Saturday, but it is constantly with me as a reminder. I sometimes tell this story to the residents and so forth and so on. It reminds me of the importance of truth. CHAIRMAN KASS: Of? DR. FOSTER: Of truth, of telling the truth. And so whenever there's an opportunity where I feel like there's something that I ought not to tell the truth because I don't want to do something, and so forth and so on, that memory, painful as it is, has served to remind me of the awful pain I felt because I disappointed this man who had given me a job to do that. So I think editing of painful things -- I have a lot of wince -- I'm not going to tell you about some of them, you know, but I'm pretty straight, you know. But still I have a lot of those. I think it would be -- I think I agree that it would be a bad thing. I think it's one thing to eliminate a memory of a plane crash or like the bus that was blown up in Israel yesterday, and you know, with people's faces drawn up. That might be, you know, to delete something like that might be one thing, but if you had to delete all of the other things from which you've actually learned and probably gotten wisdom and probably finally become something more close to what you wanted to be all your life, then I think that would be bad because then it might be that I wouldn't have that to remind me of things. So in one sense one deals with those winces by, you know, the forgiveness of friends or the person that you've had or, as Bill says, maybe if there is some ultimate judgment in the universe by that. I mentioned this article this morning because I wanted to -- of Leon Rosenberg's because I was really wanting to just talk about the issue of whether one should just fight problems or deal with them by drugs. But even though I wanted it in the archives, I think every one of us ought to read this because it's a confession in which he dealt with and did not delete the memories of his suicide attempt, of his inability to fight, and so forth. And that is now six years beyond that, and he's, you know, restored, but in some sense his need to not not remember, but to share that helped him to get well, along with electroconvulsive therapy and things of that sort. So I'm speaking too long, but I would be .- I think I would be bereft in terms of the kind of life I want to live if I deleted all of those things that were painful from which I tried to change my life from it. DR. MAY: I take it the purpose was to give me time to think through an answer, Dan. (Laughter.) DR. FOSTER: That's what I -- I was trying to help you, Bill. DR. MAY: Thank you for your collegial service. DR. FOSTER: Yes, that's right. CHAIRMAN KASS: As long as you remember the question. DR. MAY: Well, it was could you justify interventions, I think is what you asked me, given this -- CHAIRMAN KASS: As a healer of souls, yes. DR. MAY: Yeah, and traumatic memories can be of an order to do something by way of offering provisional shelter for them, it seems to me. One would have to be satisfied that we know there are traumatic situations where people are so reliving it that, in fact, much else in their past is wiped out, and so it isn't as though you're simply wiping out the past. You may be sheltering them from certain events in such a way to allow them to reappreciate full ranges of the past that in their obsession they are not able to relate to, but one would hope that it is a limited and provisional shelter. One would hope in total coherence to allow them even to face up to that event. So it would seem to me a kind of limited provisional justification. CHAIRMAN KASS: Let me bother you just one small point further on this. It turns out, and it's mentioned, I think, in Gil's paper and also in the staff paper that at least with the memory blunting agents now under discussion, they would have to be taken within a certain short period of time after the event because this has to do with the consolidation. DR. MAY: Right. The consent issues are there, too. CHAIRMAN KASS: No, not so much the consent question as much as the question of do you think one would know on the occasion whether this is the kind of an event deserving of such shelter for the sake of the rest? DR. MAY: I don't know. I certainly -- CHAIRMAN KASS: Or is there some sense that Gil's remark about the unknowability of the meaning of any of these events might lead you to say, well, we can't edit in advance? DR. MAY: Yeah, I certainly think one would need to be cautious because it would be very quickly, immediately justified for managerial purposes that you would shoot them up in order to manage them, and whether it was really serving them or whether it's something that they could more directly face might tend to get institutionally repressed. CHAIRMAN KASS: Can we continue on these? Let's see. Robby, on this? PROF. GEORGE: Yeah, just on this because I thought what Bill said was very good, but, Bill, I wonder if you would accept a friendly amendment or maybe I've just misunderstood. I think the way you summed it up at the end with what you were arguing for was you said you were offering a limited provisional justification for sometimes blocking. DR. MAY: You can imagine certain -- yeah. PROF. GEORGE: But it sounded to me like what you were offering was something slightly different. Rather it was a justification for a limited provisional blocking, the distinction here begin, I take it, if I can kind of fill in the background to make sense of that, it would be the idea that the -- I hate to put it in such sterile, analytic terms, but if you'll forgive me just for the moment that the truth of the proposition is always a reason for knowing it, but it's certainly not always a conclusive reason for adverting to it, especially in view of the fact that very often propositions that we know and can actually avert to in terms of memory are emotionally just awful. So that in view of that and without in any way attacking the value of truth itself, the value that makes the truth of a proposition the reason for knowing it, we can have reasons for purposes of health, psychological health, doing something to blunt the pathological implications of our inability not to avert to that horrible memory in this or that case. Am I on your wave length or have I changed your -- DR. MAY: Yeah. No, I think that's right. Timing is very important. CHAIRMAN KASS: Michael and then Paul, Mary Ann. Michael. PROF. SANDEL: Bill, you were addressing half of the question of intervention, the one you had been asked about. Should the doctor of the soul over here intervene to block someone forming a memory? What about the opposite side of that question? Should he intervene with the patient to dredge up for them a memory that they've already blocked? Is there any reason why he should intervene or not -- did the same reasons operate on both sides? DR. MAY: Well, and Freud depended heavily on the latter obviously. PROF. SANDEL: But are the considerations different or is this symmetrical? DR. MAY: Well, and I felt part of the justification, as I recall it, was that in failing to retrieve those memories, one is often fated to engage in repetitive acting out because one hasn't dealt with the buried memories. Is that right, Paul? PROF. SANDEL: Maybe, but it may also be an act of kindness or compassion or humanity for Paul to leave some of those buried memories alone, wouldn't you say? Or is that always a failure of respect because you're not bringing the person into contact with the truth? CHAIRMAN KASS: Well, let me make this slightly more complicated, and forgive me for jumping the queue, but it's a continuation of this thought. One could make an argument in advance that there are certain things that we would be better off not knowing. If you know what you're doing, you don't really let people to go down and view the dismembered bodies that have been strewn after an explosion, whatever their voyeuristic curiosity might be. And if you could make an argument that a certain kind of ignorance might be salutary and preventable, therefore, what do you do if someone accidentally stumbles upon a kind of knowledge which would be terribly disorienting and produce all kinds of painful effects through no fault of their own. I mean, you know, Ham walks into the tent and sees the nakedness of his father. Now, he shouldn't have been in the tent, but we're better off if he hadn't seen it, and if we could somehow blunt the memory of his father's disgrace when we would have prevented him from witnessing it in the first place, why not? PROF. SANDEL: Right. That's the -- CHAIRMAN KASS: That's the kind of line of -- that's in keeping -- PROF. SANDEL: Exactly. CHAIRMAN KASS: -- with your thought. PROF. SANDEL: Yeah, and that seems to me the bigger issue. PROF. GEORGE: Well, you certainly don't want to -- sorry to interrupt, Leon -- but on this I think that the baseline from which we're operating here was provided by Gil. We don't want to validate the idea that it's okay to live a lie. We want to take as our baseline that people should live, that a life well lived is a life lived in line with the truth. But we're wondering if, consistent with that, it's sometimes appropriate to blunt or block access to certain memory. So I think we need to distinguish and see if we can put any analytic rigor into distinguishing that blunting and blocking from falsification. PROF. SANDEL: The truth ain't everything. CHAIRMAN KASS: I'm sorry? PROF. SANDEL: The truth ain't everything. CHAIRMAN KASS: That I guess is what's under discussion. Paul and then -- DR. McHUGH: Yeah, I want to come back really with where Michael began here and then come to what's being discussed. The essence of memories are that we do affect them and shape them and lose some of the details, but the interesting thing is that we often keep the gist of the memories, a certain aspect of gist is sustained. So what is this biological function we have of remembering things in which there is a fall-off of detail even though there is a conception of gist? And I work, after all, with people and their memories and the like, and I can validate a lot of things that Bill is saying, including, for example, that when they're in a particular state of mind all of these nasty, wincing things come back up to them, and they'll say things to me like, "Well, that's really me." That was, you know, "I told a lie. I'm really a liar," or you know, "I went to a peep show and I'm really a sex fiend," and things of that sort. And that's usually coming out of the illness, depression, the disease depression that picks out particular memories and gives them tremendous salience, and I want to correct the depression, and then when I do that, these memories fade back into wincing experiences of the very sort that Dan is talking about. But there's something else about having a memory capacity that keeps a gist and loses some of the details because we work with that in psychotherapy all the time. Again, I have people come in to me with a whole variety of -- who will bring a life story to me, you know. They bring the story, and they say, "Look. I don't know if you can help me at all with this, but this is the way I look at myself and look at my background." And some of them, for example, bring in, you know, "I was psychoanalyzed for a long time and spent all of my time wondering about my Oedipal complexes and things of that sort." And I sometimes say, "Well, why do you come to me after that? You know you're going to get something else if you come to me." But the issue is that we now know this about people, all people seeking psychotherapy, and that is that they don't have the same story. They don't have -- they're not all Oedipally conflicted. They do not all, in fact, have sexual conflicts the way Freud thought. The thing that they have in common is that they're all in the same state of demoralization. Somehow the way they are looking at the world, the things that they have experienced, the things that have happened to them have demoralized them and have lost for them the capacity to go forward. And my job is not to eliminate the memories that they have, but to give them a different salience in their life. I mean, we've just heard this wonderful story from Dan. Now, you told me a little homely story. Suppose he had come to me and said, "You know, Paul, there it is. You know, I'm still sick about it. Can you help me?" And he might come in and say, "Can you give me some Prozac?" I would say, "No." I would say I want to look at that story. The gist of it is correct, but I want to look at it as a young fellow who learned something and who had the character to be shamed by that and from that time on, his character, which is the thing which has led him on into other things, is reflective of his abilities and, therefore, give him hope, make him believe in himself again. You've got to believe Dan. You've got to believe that you have wonderful things, and the essence of the memories that allow things to fall away and yet keep a gist is that I can tell a better story for the patient than the one that he brings in that demoralizes him, and I give them a better way of looking at it. Now, is it the truth? Well, since the story he brought in wasn't the truth, then the story I'm giving him isn't what you -- that was a wonderful -- isn't a secretarial truth, you know? A day-by-day chronicle, it is. He's got a view of it, and I have a view of it, and I want to give him my view because I think it helps him believe in himself and believe that he has mastery over the future rather than to be demoralized by it. And so I think the reason that we have this memory that is not a videotape of the world is just for that reason. It allows us to eventually get hope and develop it, sometimes by help from a coach like me, but often by ourselves. You know, Dan has come to terms with that. I'm not going to tell you any of the wincing stories about mine. Oh, awful, but we go on. And so the third point I want to make is about these traumatic events, and I'm very concerned about anything that's going to try to eliminate the memory of the traumatic event. I'm very happy to help somebody who has had a traumatic event and is not sleeping, is anxious and agitated, is house-bound and things of that sort. I see plenty of them, and I help them with those symptoms even as I sympathize with them, with for example the loss of a child or something of that sort. Well, I'll help him or her with the symptoms, but I don't want to take the memory away, not only because I think the memory has value in them, in their life story and their chronicle, but also I think that the memory reminds them of the dangers that they're in and what they need to -- you know, these other symptoms give us a chance to avoid things. And then to finally come back to this idea-- Do you want to dredge up memories because you think they may be the pathological ones? Well, that is what has provoked the so-called memory wars of the '90s in which the theory was if you have these moods, you must have something buried, and it's going to be sexual, and it's going to be this. And, again, we could install that, but that turned out not to be so much a memory as a belief. These people were not -- they called it, "Well, now I remember," but actually it was a belief, and you can even see different things light up in PET scans on them as they try to pull it up. And our job is not to instill those kinds of false beliefs in them, particularly a false belief that encourages the view that you're a victim. I don't want to make anybody feel they're a victim. We've all been victimized, and little guys have been victimized more than tall guys. But we don't want -- (Laughter.) DR. McHUGH: But we don't want to live our lives and go forward just remembering or thinking about ourselves as victims and these recovered beliefs and all, finally the memory wars are over, but they were an effort to produce beliefs that were not good stories. They were stories that ultimately invalidated people. So I'm coming back, coming around to the other thing. Would I want to eliminate a painful memory from somebody? Not really. I would like to relieve the pain if I could, make it less, but I want people to have the gist of their memories, and then they may need help in shaping them in ways that continue to make them feel they still have mastery over their future. PROF. GLENDON: What I have to say actually is related to what Paul said. I agree with your cautiousness about not wanting to take away a traumatic memory, but I wonder if you would accept a distinction between the kind of trauma that a rescue worker may experience in that nightclub fire in Rhode Island or in the World Trade Center? And it seems to me between that kind of trauma and the trauma that is directly tied up with one's life story, the loss of a loved one under violent circumstances, it seems to me I'm not altogether persuaded that it wouldn't be appropriate to help the rescue worker take the pill, you know, even preventively because they know from photographs and other things in their training. They know what they're going to see, but do they need to see 90 -- well, you know, we know what happened there. DR. McHUGH: Well, it's interesting that there are data on that in relationship to a major, major disaster, the disaster known as the Piper Alpha disaster, the fire in a North Sea oil rig in which it turned out that there were rescue workers later that went in and brought the bodies out. And the thing was that the rescue workers had been examined prior for other reasons. They had been given psychological assessments, and there were then two groups of rescue workers, ones that were just given no assistance, just thrown into the bodies, the morgues, and the other one in which the psychiatrists in Aberdeen were with them throughout, reminding them of the good that was coming of bringing these bodies out for the families, giving them a continuing story about this horror. And the interesting thing was this second group of people -- we talk about grief counselors going in trying to get people out. They're no use, but if you can give a story to people during their rescue work and recovery work, they manage it. They put it into there and they said, "No, this is a stinking, dirty, violent work, but it means something to somebody else," and that helps them, and you can do that without a pill if you can make it clear and help people in that process. The Piper Alpha disaster story was spelled out by the psychiatrist, and it's an absolutely fascinating subject in relationship to traumatic memories. DR. GAZZANIGA: So we can't be simplistic about this, and we've done the typical thing that we all do, which is take this and plant it, I mean this traumatic memory and this drug, and we're going to block the traumatic memory, et cetera, et cetera, et cetera, and that's just not how it works. That's what I'm trying to tell you. It's a continual updating of an event that gets changed naturally through time. And the second point is that 90 percent of the people who have a traumatic experience have no problems later on in life of a psychiatric nature, and that what the event does in many instances is it simply triggers a predisposition for a mental condition that will find them at one time or another probably winding up in Paul's office. So you can't just take this little simple view of the brain that there's this memory. You can encode it. You can block it. You can do this; you can do that. There's a lot of overhead, of mental overhead in the psychological structure of the person. Maybe the people who aren't traumatized by this have already told themselves the story. There's obviously a reason to go in and get these people out, and so they naturally self-administered this sort of thing. But finally, just to -- yeah? CHAIRMAN KASS: On the first point, you're now suggesting not only does memory get modified through the retelling and revisiting, but are you also saying that the suggestions of the sort that we hear and that have, in fact, been reported in a way in the literature, that even that is rather simplistic; that there is no such thing as in the process of memory consolidation altering the affective character of the way that gets remembered? Just as a factual question. DR. GAZZANIGA: There are people who react to -- you take 100 people and show the same traumatic event, how they react and what they take away from it varies all over the place. CHAIRMAN KASS: Agreed, but is there no way to intervene on the occasion? DR. GAZZANIGA: Oh, there are these manipulations as reported, yes. Yeah, yeah, yeah. CHAIRMAN KASS: Okay. DR. GAZZANIGA: No, I'm not saying that. CHAIRMAN KASS: Okay. DR. GAZZANIGA: Let me go to Paul's point on this because this is one I happen to know about. The danger of the implanted memory that we all -- the psychiatrists certainly worry about this as they talk to people, and culturally there's a social psychologist new school, Henri Zukier, who was doing a study on the Holocaust syndrome, and he noticed that he could understand the Holocaust syndrome being a reality, but his suspicions began to grow when the children of the Holocaust event had the Holocaust syndrome. And then finally the coup de gras was the grandchildren of the Holocaust victim. He said, "How does this work? You know, we're now two steps away from it." So he said he thought he'd go investigate the Holocaust syndrome, and he said, "I'll go to Europe where obviously it would be intense," and he went to the psychiatric communities of Europe on the Holocaust, and they said, "What are you talking about? There's no Holocaust syndrome." And he went and did all of the proper scholarship of this and discovered this was an invention of New York psychiatrists that this existed, and they built the syndrome and people came, and in so much of what we're talking about here, we are building syndromes and people come and they are assigned into these categories, and then we as a culture have to live with it, and that's a big problem. DR. McHUGH: And we put them in DSM-IV, by the way, operational criteria. CHAIRMAN KASS: Gil and then Bill and then Michael. PROF. MEILAENDER: Comments on a couple of things. On the rescue worker issue, if you think that Mary Ann was building up sympathy for, and I can understand it, but if you think about it, we're going to have these people take the pill preemptively, so to speak. That blunts the memory. Part of what's going on is you wouldn't think that someone could go through the whole of his life doing this. I mean, imagine just a lifetime spent as a rescue worker dealing with the horror of dismembered bodies. That suggests to me that maybe nobody should do this for his life, for a whole life, you see, because otherwise the notion is that it would be fine to sort of create a group of people who, as it were, could do this for their whole life and not be bothered by it. That seems to me much more troubling than the notion of, you know, letting some people have these memories and then trying to help them deal with it. So, I mean, if you think about it from that perspective, it seems to me it raises questions about doing it, and I thought that Paul's example was nice in that it suggested a way of dealing redemptively, to use the category that I use in the paper. So that's one thing on the rescue worker. And then the other thing, just the question. I mean, I assume that there are some things that it would be better not to know probably. The question is how you are to live if you do know them. That's the question, how you are to live truthfully as a human being. And I don't think that my claim in the paper was that one lives truthfully in the face of that just by passively accepting it, saying, "Well, there it is. I know it sort of," or something like that, but rather that one lives humanly with it perhaps simply by sort of stoic fashion, enduring and bearing up under it; perhaps by gradually finding a way of telling the story that transforms it in such a way that it gives it redemptive significance and either or both of those may need the help of other people in order to accomplish. It's not just something one does. So those are sort of humanly fitting ways, it seems to me, that one lives truthfully with such events. They're not the passive acceptance of it, but neither are they denying that this is now part of who I am and I need to find a way to deal with that as part of who I am. CHAIRMAN KASS: And for those people who are not blessed either with faith and redemption or the strengths to be stoics and for whom this is just pain, disorienting pain, and who, by the way, may not have community that can help them deal with this, suffer little children. PROF. MEILAENDER: You can always make a problem go away and free ourselves of the responsibility to be the community that helps them by hypothesizing such circumstances, but, I mean, it's just there might be such circumstances, but I wouldn't create a policy. I wouldn't create my general attitude toward the question on the basis of that because, like I say, that let us off too easily. It lets us off the hook of trying to find ways to serve their need. CHAIRMAN KASS: Bill Hurlbut -- on this? PROF. DRESSER: Just indirectly. It seems there are two issues. One is do we want to concede that there are cases where this would be the best thing for the individual, and I remember -- maybe I'm misremembering -- but I think Dr. McGaugh talked about the post traumatic stress disorder, the Vietnam vets who were really paralyzed. I mean they could have no life, and he seemed very moved by those cases. So I wonder if we want to say that that would be a case where we might think it could be justified. But then the second question as Gil puts it is it seems if you want to frame the intervention as, well, the only way this is going to work is we have to give this to everyone after the Vietnam War or while they're having these horrible experiences, and we know there's, you know, three percent of them who will be able to function after this because then all of these other people won't be able to process the memories in a way that we think is meaningful. DR. FOSTER: But remember that you have to use these drugs either before the event or immediately afterwards. I mean, you can't come back ten years later. Then if you have a deletion, you delete all memories instead of the very painful one. So you'd have to say, as I think he said, that maybe we're going to give beta blockers to people who are going into the dessert here ahead of time. So the big problem that they talk about, the deletion requires anticipation or immediate intervention within, you know, a very short time. CHAIRMAN KASS: Bill Hurlbut and then Michael. DR. HURLBUT: When I read this, when I read Gil's paper, it struck me there was a lot of implicit reference back to Leon's paper from last week or last time we met. The notion that we need to keep life coherent so that we can participate in the intelligible world. I want to make a comment, but I want to ask you a question on the way. Is there such a thing, Paul, as a memory that in a -- let's talk about healthy adults for the moment -- that cannot become like the grain of sand in the oyster that can't become something richer and deeper? Are there truly destructive memories? DR. McHUGH: Well, you know, I think you can have a memory that you make destructive, and you certainly can have an event that you remember that alters your life script. I mean, let me just tell you, for example, we now know that the sexual abuse of children by an adult which has been summed up often in the traumatic area, the problem that it produces later in life, and it does produce plenty of problems later in life, has less to do with the trauma or even the memory of that event and everything to do with the change in attitude that that child takes about sex itself. Okay? We were just talking about that before. That child, because of the adults -- by the way, it has to be an adult. It's not some playing doctor and peer interactions -- an adult that comes in and breaks into the relatively latency period of childhood, that memory teaches that child some things about sexual life that are destructive. There should be more partners, and they have more partners; that they have very early consensual sexual experiences. They develop sexual diseases. They have early pregnancies and the like, and the bad outcome that we know about has more to do with how the script changes because of this event, not the memory. But if you looked at it, the memory has produced the script, and so there are four. It's a bad thing, but what the psychiatrists do now for these children, in my opinion, is not that he goes in and tries to eliminate this awful memory, and it's awful that the person has been so intruded into, but they immediately begin to start laying out, well, let's look at the way we'd really like you to think as a person about this very important part of life that you're going to have to grow to, and the thing that has happened to you has made you vulnerable to a pernicious and potentially very pathological life course. DR. HURLBUT: So that's the key then, isn't it? The script that you, the story that you contain your events of your life in is the story that you want to sustain in its intelligibility and work toward a deeper comprehensive understanding of the world as you go, as you go forward. That's what the human soul is. And it seems to me that beneath so many of the questions we've been discussing for the last six months is hidden and we haven't spoken of it very much, but is the question of what is the role of disturbing suffering in this formation of the life story. Over and over it just seems like biotechnology is offering us the opportunity to avoid that which is uncomfortable or eroding to our self-esteem or bad memories or, you know, no decline in aging. It's interesting. Earlier when we were talking about the compression of morbidity and so forth, it stirred a memory, a good memory. I read that Vincent Van Gogh wrote a letter to his brother Theo saying that he didn't want to die suddenly and comfortably. He wanted to die of a very wrenching disorder like tuberculosis or whatever it was in his vision, but he said that that way it would be like a booster rocket that would send him off in the trajectory of eternity. And I'm considering how the guy died. It's a very poignant thing to have said, but what strikes me is that at least -- and what's so powerful about his art is that you feel the suffering -- at least I do -- feel the suffering in his art, in his life, and I for one don't want to tell myself a story that's a fiction. I would like to go to the bottom of the story, and I think at least somebody in our society has to face the very worst there is in human existence or we're all in trouble. And probably all of us, to the degree we're capable of it at least, and whether there's some place for childhood and not having memories or something, but the overall thrust of the thing, it seems to me, ought to be to participate in this intelligible language of being, which includes suffering, and to more and more understand our lives at the depths of the reality of the world. I was wondering what we're doing on this side of the river, and I was think that maybe, when we were running last night -- I ran by the cemetery -- and I was thinking, "Is Leon such a thoughtful genius that he put us out here next to this memorial of human's noble sacrifice?" Because finally in the end, we know that's what makes a meaningful life, is whether you're called to it or not, that finally you go that deep, that you know what the world is, that the world involves suffering, and you don't do what they did in Brave New World, which was, you know, basically "Christianity without tears." As they said, "Nothing costs enough here." And the one line that kept coming back to me from Leon's paper was, that finally human flourishing rooted is aspiration born of deficiency. Well, I think we need to for the fullest lives go to the fullest depths of that deficiency. CHAIRMAN KASS: Michael, and then I think unless there's someone in the queue -- Michael, Alfonso, and I think we'll call a break. So thank you. PROF. SANDEL: Listening to the discussion, I think I've heard two different kinds of arguments against this memory blocking pill, and I'd like to distinguish them. One of them seems to base the objection on the idea of the deliberate forgetting, that to take the pill to forget a trauma is to artificially willfully forget. And moreover, since we have to take it at the moment, we're not in a good position to decide then whether it's the sort of thing we should forget or suppress. That's one objection. A second objection goes deeper and depends on the claim that it's always good to know and face the truth, and this stronger claim seems to me questionable, and it's questionable for reasons, Leon, brought out by your example, a biblical one, but there are lots of truths that we every day try to spare our children or loved ones. Sometimes when the newspaper has a particularly gruesome photo, I take it and hide it not only from my kids, but even from my wife just to spare them. Now, I'm depriving them of a certain truth. Now, I don't know if I would conclude from that that if they did happen to see it before I removed it I would give them a pill to forget it, but is there a difference in principle between the first impulse and the second? But here's a way of testing whether these two reasons go together or whether it's possible to distinguish, whether it's really the deliberate, willful character of it that's objectionable. I mean, this is may suggestion or hypothesis. Here might be a way of testing that. Suppose we remove the deliberate, willful, artificial aspect of the dulling of memory, and consider a case where not a pill, but nature systematically dulls a traumatic memory. Now, I don't know how scientifically well founded this is, but there is a folk- lore that the memory, the full memory of the pain of childbirth is dulled, and that if it weren't, there would be fewer children born, and we were told this -- I don't know .- when we went to child- bearing classes, you know, where they teach you, and this is purely anecdotal, but my wife completely believes and supports this anecdotally at least, that if women really did remember from one child to the next they would have as many kids. CHAIRMAN KASS: Scopolamine, I think is what it is, right? PROF. SANDEL: Now, here would be a case, if this piece of common folk- lore is true, where it would be nature, not a pill- dulling traumatic memory. Would we regard that as regrettable? CHAIRMAN KASS: Gil, do you want this? PROF. MEILAENDER: I don't know quite where your piece of folklore comes from, but I know that there's a story that the rabbis supposedly told asking why a woman had to bring a certain kind of ritual offering after giving birth. It probably had to do something with ritual purity and so forth. But the answer the rabbis gave was that it was to atone for a vow she made but never really intended to keep. That is to say when she was in the pangs of labor, she vowed never again, but when the child was born, that is to say when she saw what the event meant in the light of the whole or at least a fuller story, saw the fruition that gave real redemptive meaning to the labor, she realized that she never intended to keep that. Now, that's not a bad example of what we've been talking about. PROF. SANDEL: Well, Gill, neither you nor I may be in the best position to testify on this question. So I would still put the hypothetical. If nature dulls traumatic memory in the case of the pain of childbirth, is that something to be regretted? (Laughter.) DR. FOSTER: Let me just say scientifically -- CHAIRMAN KASS: We now have an authority. Mary Ann. DR. FOSTER: Just to answer your question. PROF. GLENDON: Well, I have to disagree with you, Michael, in characterizing it as a traumatic memory. I think, first of all, pain, and the medical people know better than I do, but I don't think we remember pain, physical pain of any sort quite the way -- I mean, that's a funny thing, that memory of physical pain, and I think it is quickly forgotten. I mean, you know that there was a painful experience, but it's not like the memory that made us all wince when somebody mentioned, the mere mention of the wince factor all around the table was a shudder because we all have those vivid memories of the wince, which are more vivid, I think, than the pain of childbirth. DR. FOSTER: Well, what I was trying to say is that most scientists think that those are the release of endorphins and enkephalins, you know. We don't have an opiate receptor in the pain so that you can take heroin. There are many people who come through great trauma that have burns and so forth who have no, as Mary Ann says, who have no or little memory of the pain, and so we do have these endogenous opiate-like molecules that are released. And I think that what she said is probably exactly right. PROF. SANDEL: But do they dull the pain or did they dull the memory of the pain, Dan? DR. FOSTER: I can't answer that. I presume that because of their biologicals, they probably dulled the pain more than the memory of it, I would guess. CHAIRMAN KASS: Alfonso, take the last, and we'll call a halt. DR. GÓMEZ-LOBO: Yeah, actually this hooks up with some of the stuff that Michael was saying. Let me start with a question about nature, if nature dulls it. You know, the more I hear about enhancement around this table and the lot I heard last week in the conference on the Future of Life out in Monterey, the more I tend to think that we, I mean, humanity may not be on the right path. One thing -- (Laughter.) DR. GÓMEZ-LOBO: -- one thing that strikes me as deeply wrong is precisely the malleability about which Professor Pinker was talking. It's this sense that everything can be changed, like we can walk in there and, you know, change virtually everything. Now, it seems to me that or I would like to retain the idea that nature is a very complex, marvelous system of causality with a few glitches. Surely there is illness, and there are very good reasons to work against it. But there are other domains where I just don't see the point of going into it. Now, some of you are going to accuse me of unilateral disarmament, and that may be a correct description. I tend to unilateral disarmament myself because I think I should measure thing against my own personality, my own authenticity and not necessarily against my competitors. Now, that said, I would delighted with Gil's paper not only because of its depth, but because it provided, it seems to me, all sorts of arguments to say let's leave this domain untouched. One of the great reasons, for instance, that I saw -- and this is really for me going to be a memorable phrase -- "not to remember the face of evil is to miss the evil of which we ourselves are capable." Now, I'm not a psychiatrist, and I can understand that there can be traumatic memories, but, on the other hand, I think it's very important to remember certain things. I myself lived on the road to Dachau for almost two years in Munich, and I used to take visitors to the camp. I suddenly discovered that I was no longer taking anyone there after, you know, about half a year, but it's one of those things that in a way I'm grateful I haven't forgotten. So I would say efforts -- I know this is very difficult, but it seems to me that efforts should be directed to trying to draw lines between therapy and the domain beyond therapy and really think whether we're doing something reasonable in all of these efforts, which by the way don't see to be very fruitful from what I've gathered. I mean, we haven't made much progress in suppression of memory, if I understood correctly the two papers. We don't seem to be very close to getting to designer babies, and so I know this is very emotional on my part, but I think that there's something very deep to think about here, and it is what are the human goals that ultimately are going to be worthwhile. Are we really distancing ourselves from nature and under the illusion that we can do better than nature? I have serious doubts about that. CHAIRMAN KASS: Thank you very much. One sentence to two sentences. This will be the last formally scheduled, I think, discussion of this topic. For some of you that's extremely good news. I think if I might be indulged an editorial word, it's true that some of these vaunted technologies are at the moment at least less than they're cracked up to be when announced in the newspapers, and that's a useful thing to have learned. But in all aspects of this beyond therapy project, I think we've seen how these new powers, in fact, do touch upon all kinds of things that are really quite important, and the number of things that we've talked about, whether it's the life cycle or the relation to our bodies or the question of memory and the story of the life, these really are the essential features, it seems to me, of at least part of a richer bioethic. And I would like to think that a serious discussion of those things, whether it justifies the expenditure of the taxpayers' money, and certainly it's not going to lead to any immediate public policy questions, but it does seem to me that there's an opportunity to do some kind of education of what might be at stake here, where we are, in fact, from knowing what to do, and even a certain cautionary note about whether we know what we were doing if we were doing it. That I think is to be the spirit of what we will try to write up and circulate amongst you for discussion, if all goes well, before our next meeting. Tomorrow morning, beginning at 8:30 we have two presentations on the self-regulation of the assisted reproduction profession/industry. We have presenters, and this is a return now to the project on regulation and public policy, and it should be really quite, quite interesting. Let me urge people to try to be on time at 8:30 because we will have a guest to present. You are free for the evening. You will not have to stand in line to get your dinner bill, you know, paid for for an hour, and I wish you good evening, and we'll see each other in the morning. (Whereupon, at 5:31 p.m., the meeting in the above-entitled matter was adjourned, to reconvene at 8:30 a.m., Friday, March 7, 2003.) |
