Dr. Pellegrino

Dr. Edmund Pellegrino came to BC to deliver the LaBrecque lecture in medical ethics last night--there was a good turnout. He also gave a luncheon seminar today.

Today he gave a short overview of the President's Council on Bioethics and the work that it is doing. There is a growing recognition that bioethics is increasingly a matter of public policy. The council advises the president on various ethical implications of public policy.

In 1972 bioethics was "baptized," and a national commission was established in 1977 to study various issues, especially human research. The Belmont Report came out of this national commission, laying out 4 principles of bioethics:

1. autonomy
2. beneficence
3. justice
4. non-malificence (which some distinguished from beneficence)

This commission was succeeded by a Presidential commission studying human research and the ethics of behavioral science.

In 1983 a series of reports were issued. (Not sure by whom.)

A congressional commission was formed during the 80s to study the moral status of the fetus. There was only one meeting--one of the members passed away, and Congress was unable to settle on a replacement.

Hiatus of 13 years?

President Clinton appointed the National Bioethics Advisory Committee which was stacked towards approving anything new. It was a White House appointment. Dr. Pellegrino believes the current Bioethics Council differs from the Clinton one in that it is "surprisingly well-balanced." Dr. Pellegrino sees himself as a political independent.

"Bioethics is everybody's business." The Council does not make policy, it is just advisory; its mission is to lay out issues as thoroughly as possible, both for the public and for policy makers--to lay out issues of fact. The Council does make policy recommendations, for example the moratorium on human cloning.

What place do philosophers have on the Council? There are two extremes of opinion:
1. No place whatsoever, since there is no such thing as an expert in bioethics, philosophers aren't experts at anything, they have no experience with medicine and science, etc.
2. Everyone on the council should be a bioethicist.

When it comes to actual philosophers, there is only one who is currently on the council, Alfonso Gomez-Lobo. Michael Sandel is no longer on the council. There are 18 members, all are presidential appointees.

Current topics for discussion:
1. Organ transplanation -- including, Are brain death criteria defensible? (When should a person be considered dead? Circulatory death vs. brain death.) How are organs to be allocated? Can organ donation be commercialized? Is it really morally permissible to have a living donor? (It has been discovered that those who donate do suffer from complications--kidney donors suffer from hypotension, etc.)
2. Newborn genetic screening -- should it be required? uniform on a natinoal basis? (PKU, etc.)
3. The concept of human dignity?

Dr. Pellegrino hopes these reports will be issued in the next 6 months.

All meetings of the council are public--there are no secret meetings, no executive privilege--everything is on the public record. (Sunshine laws) The members are very careful when it comes to making everything public, and Dr. Pellegrino has made things even more strict.

They are the first of 7 or 8 topics, which include justice in health care and professional ethics. The topics are chosen by the council itself, though they did receive one request from the White House, and that was to present a report on cloning.

What of the conflict of obligations? I have an obligation to my patient, but also to the common good. The individual doctor has a responsibility to his patient, they have a covenantal relationship; but he also has a duty to the common good and to decide wisely the allocation of limited resources.

(Chromosome Six, by Robin Cook -- using bonobos to create human organs)

How to define a bioethicist? What are a bioethicist's qualifications? At present there are no specific criteria for declaring someone to be a bioethicist. (Dr. Pellegrino declares that he is not one.) Generally, anyone today can declare himself to be a bioethicist if he has studied the subject. One can be trained in "bioethics" (Dr. Pellegrino does not necessarily approve); there are 105 bioethics centers around the country, but no formal process of certification. Bioethicists have a presumed expertise; people believe that they can provide a more reliable way of making ethical decisions. (But this of course is not necessarily true--one can be an "ethicist" without being ethical."

Doctors should help analyze the problem, make recommendations about the best course of medical treatment, but refrain from talking about values/ethical judgments. Doctors can consult about human relationships (getting family members to talk to one another), and prudential judgments. Doctors have medical expertise.

Dr. Byrne: autonomy and dignity are leading principles today
However, choice was initially associated with something.
For Kant, with reason. For Locke, with bodily integrity in the state of nature (law of nature). But now there is no more rational underpinning.

A lawyer and member of the council, Carl E. Schneider, has written a book on autonomy: The Practice of Autonomy: Patients, Doctors, and Medical Decisions.

Dr. Pellegrino points out that autonomy also exists for the physician, nurse, etc -- one cannot violate their conscience in demanding a service. (Martin Buhl? talks about I and thou in the decision-making process.)

Dr. Pellegrino supports universal health care and a single-payer system; he believes that such a system does not entail Federal management of health care, or a new bureaucracy. Private insurance companies should be done away with. Dr. Lebrecque argues that the profit that would be generated should instead be channeled into providing health care.

Rationing/mechanisms for allocation would not be decided by the Federal Government, but health care would be Federally funded.

Dr. Byrne: The profitability of insurance companies drives efficiency, cost-effectiveness?

Dr. Pellegrino: Mandatory health care insurance, one pays in terms of net income--everyone should have access to basic medical care. HMOS: control costs to increase top-end profitability.

Bad fortune cannot be avoided, but what about responsibility for one's own health?

Another member of the Lebrecque family argued that costs for private insurance increase because of mandates by individual states.

Dr. Pellegrino: Is health care a commodity? Is it fundamental? What kind of society do we want?
Adam Smith would not treat it as a commodity, not subject it to the "laws" of the marketplace.
You get the kind of health care you want. How does health care fall under justice? He claims that we can afford it. In a survey of officials of different countries, they prioritized health care needs as follows:

1. sure access of everyone to emergency health care
2. chronic/disabling illness
3. maternal/child health

Very few talk about preventive medicine; to do it well is expensive, as it requires constant human input and behavior modification. (Habits are involved.)

But how important is life and the good of health? Enough that others should pay for my health care when I have failed to be responsible for my own health? One should have access to a doctor; but where do the expenses come in? Diagnostics? Treatment and procedures?

Dr. Pellegrino claims that in rural areas there are a lot of people who are untreated. (His first job was in rural medicine.) However, this may be a question of lack of proper public education and lack of transportation, not necessarily lack of quality health care.

Can certain skills be taught as a part of domestic arts? For example, first aid skills and other simple procedures for non life-threatening illnesses. What about chronic illness and disease? Old age? How much health care do I need before I should say enough is enough, and stop being a burden to others?

What are the different levels of health care that would exist in a universal system? Though the Comptroller General advocates universal health care and a single-payer system, how does he reconcile this with his warnings about the impending bankruptcy of the Federal Government?

At the Modernity conference someone gave a talk on health care--was it Peter Riola?--he emphasized that the basics of public health included sanitation, water, and infrastructure. As for the other details... I'd have to try to remember them, but if his paper got published that would be good.

What of obesity and the illnesses that are caused by it?

Georgetown Clinical Bioethics page; Philosophy page

Virtual Mentor profile
CBHD: Meet Edmund Pellegrino
bioethics.net :: Reflections on the Appointment of Edmund ...
blog.bioethics.net