Articles Blog

Amy Gutmann & Jonathan D. Moreno: 2019 National Book Festival

Amy Gutmann & Jonathan D. Moreno: 2019 National Book Festival


>>Paul Farhi: Good afternoon. This ought to be interesting. My name is Paul Farhi,
I’m a reporter with the Washington Post,
and it is my pleasure to introduce this
distinguished panel. We have one of America’s
greatest television journalists in conversation, with two of America’s most
formidable intellectuals, Doctors Amy Gutmann,
and Jonathan Moreno. They will be discussing their
book, Everybody Wants to go to Heaven, but Nobody Wants
to Die, subtitle Bioethics and the Transformation
of Healthcare in America. Let me introduce this
distinguished panel. Andrea Mitchell,
no introduction, everybody knows Andrea Mitchell. [ Applause ] To compress the very
extensive resume down, veteran chief foreign affairs
correspondent for NBC News, also host of Andrea
Mitchell reports on MSNBC — noon, check local listings. Joined NBC in 1978 and has
covered seven presidential administrations, every presidential
campaign since 1980. You’ve seen her on nightly news,
The Today Show, Meet the Press, she’s been everywhere. Conflicts in Haiti, Bosnia,
Kosovo, she’s been to Iraq, Afghanistan, North
Korea, Pakistan, Israel, the Palestinian territories. The awards she’s won would take
me all day, so I will just go to one; she just won, this year, the women in Washington
journalism Lifetime Achievement Award. [ Applause ] Dr. Amy Gutmann is president of
the University of Pennsylvania. [ Applause ] And has been since 2004. When her current
contract expires in 2022, she will be the longest-serving
president in Penn’s 280-year history. [ Applause ] Now again, a massive resume,
and they can get into it, but here’s one stat that I
really particularly like. Under her tenure at Penn she
has more than doubled the number of students from low
income, middle income, and first generation
college students at Penn. [ Applause ] And she’s only the
author of 17 books. Dr. Jonathan Moreno,
philosopher, historian, bioethicists; he has written
seminal works on sociology and the politics of
biology and medicine. He is officially a professor of
medical ethics and the history of and sociology
of science at Penn. He has served on numerous
Presidential advisory commissions, and he has
published more than 20 books, monographs, anthologies,
textbooks, et cetera. We’re honored and lucky to have
this unique group with us today. Without further ado, as
Lester Holt would say to Andrew Mitchell,
over to you Andrea. [ Applause ]>>Andrea Mitchell: Welcome
all, I’m Andrea Mitchell, as you know, and I can’t tell
you how exciting it is for me. I feel a little overwhelmed, not
just by this wonderful audience but by the brain power
next to me on this stage. And the fact that these are
the questions we’re all asking in our families, in our
political conversation. These are some of the
questions that we’ve heard but haven’t fully been answered on the debate stage
this primary season. Questions of who has
the right to healthcare? Many of us would argue everyone
has the right to healthcare. Who pays? How do we pay? What about the advances
in science? What ethical challenges
do we have as we you know face the issues
of where science is going, and where science has been? What is the role of the
doctor in our society? All of these questions
are addressed in this remarkable book with
its country music title. So, I am thrilled to be here
Everybody Wants to go to Heaven, but Nobody Wants to Die,
we think we should set it to music, Amy and Jonathan? But let’s talk about, the
question that has been debated in the midterms, most
recently, and now again in the general election; how
do we address the challenge of ensuring everyone in
America, deciding what to do about these hugely
expensive advances? You know who gets these
advances, at what stage of life do we start triaging? And how do we pay for it all? Dr. Guttman first to you.>>Amy Gutmann: Okay. Well, I wish I had a
one-sentence answer, but then of course we
wouldn’t have written the book if that were the case. But I think those are the right,
exactly the right questions to ask, and the context is
really an incredible moment in American history, and it’s
been a long moment since the 60s where modern medicine
gives us more choices than we’ve ever had
before in human history. But with those choices come real
moral dilemmas, you name some of them, we could add questions
about organs, scarce organs for transplants; who should
get them if they’re scarce? And we like to ask
the larger question which bioethics has
sometimes neglected which is how do you
create a system in which, encourages more people
to be altruistic and donate their organs? So, what we want to do is
open up the conversation to everybody, because there’s, if you look at these
issues every one of us in our lifetime faces almost,
every one of them actually. There are very few
that we or our family or our friends don’t face up to,
and if we don’t make the choices and we have a lot of power to
do that collectively as well as individually, then other
people are making them for us; big corporations, public
officials, insurance companies.>>Jonathan D. Moreno: At least since the 1970s economists
have said we’re on an unsustainable course
in terms of the amount of GDP that is spent on healthcare, and yet we’re not getting
enough bang for our buck. This is not a new problem, but
we’ve kind of punted on it. So, you mentioned you know
the question of the right to healthcare, in the early
1980s a presidential bioethics Commission avoided the question. We don’t think it’s
avoidable anymore, we believe that there is a right
to a decent level of healthcare.>>Amy Gutmann: For everybody.>>Jonathan D. Moreno:
Everybody, and we, part of the point of the book
is we can’t just idealize these things, we actually
have to grapple with problems ahead of us. And we have kind of not
done that historically.>>Amy Gutmann: Yeah and
so with regard to the right to healthcare for everyone,
the hard question is okay, how are we going to
afford it, right? What kind of a plan
will actually allow us to provide affordable
healthcare to all Americans? Let’s just talk about the US. And that prompted to write
the New York Times op-ed, which advocated for revising and reinforcing the Affordable
Care Act, because we are, at least our views, are
we’re very reluctant to take away effective
healthcare from people who already have it,
but we have to give it, we need a public option,
we need Medicare for more, for those people who want,
who would prefer Medicare over their own private
insurance, or who don’t, not now covered. But this is something we
all have to as Americans, I think the really the
optimistic part is healthcare is rank now is the number
one substantive issue on voters’ minds.>>Andrea Mitchell: And when we
look at costs, we know that we in America are spending more
on healthcare and getting less. We see your political figures
showing graphically, literally, that you can drive a few
miles from Detroit to Windsor, Canada and get insulin
you cannot afford. We see stories on my
network and other networks of people rationing their
insulin, which is so dangerous and potentially fatal.>>Amy Gutmann: So, just
so people know, I mean, you all may know this, but
I think all Americans need to know this, it’s that we
spend about twice as much as any other affluent democracy
on healthcare per person, and we have lower
life expectancy. Life expectancy has
actually gone down in this country since 2015. That is totally unacceptable, and we have higher
infant mortality. We and that’s just the
worst of both worlds. We have great innovation and we
can keep that innovation going, but only if we start
controlling drug pricing and other medical costs.>>Jonathan D. Moreno:
And of course, for us it’s not just the
mortality and morbidity, it’s also the quality of life. So, we have a chapter
on public health, which somewhat neglected
our field of bioethics. Bioethics tends to be
in this country focused on very high-tech
questions, which we might get to in this conversation. We also have a section
on public mental health, which has been horribly
neglected as we know. You just walk around here, and
you can see what’s happened to — our streets
have become day rooms for as the old mental
institutions were. There’s a sculpture, my wife and
I when we’re walking over here, we’d never noticed before. A sculpture of a homeless
person on a bench. So, you know we asked the
question is that sculpture there to recognize that there
are homeless people who are often mentally
ill in our midst, or is it to keep somebody, one of them from
sitting on the bench? So, we have some moral failures
that we haven’t addressed.>>Andrea Mitchell: Speaking
of moral failures I wanted to ask you about something
you wrote about in the book which I find fascinating. As we as we experience all
of these advances today, human experimentation. And you went through the history
and I found it rather shocking; we now know about [inaudible]
and other experiments earlier, decades earlier, but
I found what you wrote about Henry Beecher, and the
1964 paper about what happened in Brooklyn, New York where
elderly, disabled, you know, senior citizens were
being experimented upon with live cancer cells from
institutions as celebrated as Memorial Sloan Kettering. And then in 1966, I
believe another expose. So, talk to us a bit about
human experimentation and what safeguards there
are now, as bioethicists.>>Jonathan D. Moreno: Well the
most important single document in the history of human
experiments is called, by posterity, the Nuremberg
Code, which was written by the judges at the end
of a trial of Nazi doctors in Nuremberg, Germany
after World War Two. And our close friend,
passed away a few years ago, Jay Katz who was a psychiatrist
and law professor at Yale, was a a refugee from
Germany, a Jewish refugee. And when he was a medical
student at Harvard late 40s, during this trial of the Nazi
doctors, and the decision by the judges that included as an amendment this Nuremberg
Code, the famous first sentence of which, the voluntary consent of the human subject is
absolutely essential. And Jay said the reaction of his Harvard professors was
well that’s a really good ethics code for barbarians,
but we’re not Nazis. But almost twenty years
later, as you say, it was a Harvard
professor of anesthesiology who really shook things up, with
an expose that included a couple of dozen cases of what he said
were unethical human experiments in the published
medical literature. But this is a part of the
bigger story, all which I want to say about, we tell in the
book about the the change in doctor-patient relations
from the late 40s to the 1960s.>>Amy Gutmann: That’s
where I was going.>>Jonathan D. Moreno:
And the way that patients, and we as voters one hopes, have
insisted on getting more control over the power in
that relationship.>>Andrea Mitchell: And how
do patients get more control? As a patient myself I don’t know
whether I’m getting the right information; you are told to
get a second opinion, you know, I’m a cancer survivor,
as you know. And all of us as consumers
feel a little bit intimidated by the doctor-patient
relationship, because of the gap
in our knowledge.>>Amy Gutmann: Well it’s
intimidating, and it’s also if you look at the economics
of practicing medicine, most clinicians really
wring their hands at how little time they
have to actually sit down and talk with the patient. And no matter how
many, how automated, how technologically advanced
medicine becomes, or is, has become, there’s
no substitute for the knowledge you can
get in a two-way conversation with a patient, doctor. So, we went from
Doctor Knows Best, with Marcus Welby MD actually
being played by Robert Young, of Father Knows Best — those
of you are laughing have to be either of a certain age,
or really know TV history, but I remember it well — to an ethos, so that was the
culture it was not just the practice, we have an ethos now
of that the patient should have, be able to give informed
consent and should have control over our own medical lives,
but the actual practice of medicine has not
caught up to the ethos. So, we have I mean, we
basically there are three things that we think we, in your
position, in my position, you and I need to do,
and everybody actually, when in the doctor patient,
whenever you’re planning to go to your doctor, and
there’s something important on the line be prepared with
questions, write them down, and if it’s really traumatic,
potentially traumatic, come with a loved
one or a friend so they can help you through it. So, be prepared, be open about what what your
alternative treatments are. And know your goals. I mean, for some people it’s
extremely important to get through a wedding in the
family, or a Bat Mitzvah or a Bar Mitzvah,
and not go directly into treatment for example. And doctors are experts
in medicine, but they’re not experts in us. And we’ve really gone from
an ethos of blind trust, and we tell stories about how
that operated in our families when we were young,
to earned trust. And it’s not good to be able to
make decisions all on your own; I think a patient you know,
I shouldn’t be my own doctor, or my own nurse, but we should
make healthcare providers earn their trust, our trust.>>Andrea Mitchell: I want, one of the more provocative
questions that you raised in the book is what legal
means are appropriate for end-of-life decisions. Dr. Marino, do you
want to speak to that?>>Jonathan D. Moreno: I’ve said to my students the
last few years, other than gay marriage the most
amazing change in the culture about these kind of value issues
is the changing attitudes toward physician assisted death. I gave a talk in Kansas
City a couple of weeks ago, and I was getting ready to — once in a while I do look at
my slides before I give a talk; they don’t yellow the way my
old lecture notes used to — and I realized I had a slide
that was out of date in terms of the number of
jurisdictions in the U.S. That permit physician
assisted death. It was seven, only a couple
of years ago, now it’s, if you include Montana,
which has a legal, made a legal judgment about
this, not a statute, it’s ten. That’s a really remarkable
change in attitudes, and whether you approve it or
not, something is happening that I, we think, also reflects
the change and the balance in the nature of the
doctor-patient relationship.>>Amy Gutmann: I think
that’s a great example of why it’s important for all of
us to be informed and involved. And informed in broad ways. So, the question of
physician-assisted death is so controversial that we don’t
even agree on what to call it; the opponents tend to call it
physician assisted suicide, but whatever you call it a
very small number of people, even in the states where
it’s legalized, use it. Whereas a huge millions of
people use hospice care, and many more millions
would if only it were known, accessible, and affordable. [Applause]. It’s very important that we
understand that the things that are most controversial
aren’t necessarily the most important things even though
we need to discuss them and, being a theorist of
deliberative democracy, I think it’s really important
that we debate these things. But this culture is shifting as
physician-assisted death shows, at the sort of it’s the
tip of the iceberg, right, of how much patients have
been taken healthcare into our own hands, but not
exclusively our own hands.>>Jonathan D. Moreno: Two and
a half years ago my mother died in the nursing home in
Rockville, we had hospice, Montgomery County Hospice,
they were terrific. Anybody who’s worried that this
can get out of hand in terms of moving to too far,
bending the needle too far, I can tell you it is a
highly scrutinized process. They’re being watched
very carefully in terms of how much medication they
give for palliative purposes. So, that the way that this
was derided a few years ago as death panels and so
forth is really not helpful. And it’s again, another
way that we have kind of as a political culture
avoided getting our arms around the issues.>>Amy Gutmann: Well,
I don’t know — I saw Zeke Emanuel before,
but he’s written extensively on this, it’s been totally
distorted, but it’s been really by people who want to make
it a political, you know, just a crass political issue. But in fact, and we talked
about this in the book, there is broad agreement
on end-of-life care, but not a recognition
of people’s right to end their lives in a way
that they have some control over the pain, and the
suffering, and the dignity of how they, you know,
how they perceive it.>>Andrea Mitchell: And there’s
also palliative care at home, where there are hospital
visits and doctors, and there’s visiting
nurse visits and decisions that are made with informed
consent over not being brought into the hospital
in an emergency.>>Jonathan D. Moreno: If
you have the wherewithal to access those services, and we
were fortunate that we were able to in my mother’s case. But it’s a system that you
have to be able to figure out, have to have the time and
the energy to address.>>Amy Gutmann: Which is why
it’s so important to face up to these kinds of issues
before there’s an urgent situation, and you really
don’t have the time. This is a time when I think
the American public’s putting healthcare at the top of
their issues of concern, should spread far
beyond the politics of it to how we form ourselves
in our daily lives, both for ourselves
and our families.>>Andrea Mitchell:
Now you alluded to your New York Times op-ed
which was great and talked about Medicare for more. Just to define our terms
how do you envision Medicare for more adding on to
the Affordable Care Act? Because the debate of course
is gradations of Medicare for all and other options.>>Jonathan D. Moreno: You
know I think when we started to write the book Amy, we
didn’t we didn’t really think about the election
cycle, you know? And it’s, and we now we find
ourselves in the thick of it in the book, you know, so
relevant in that respect. Although there a lot of other
issues than that in the book. What we’re most concerned about
is first of all making sure that people who are
running for office and the incumbent are very clear
about what they’re going to do, and that we not throw the
baby out with the bathwater. We think there have been some
important advances as a result of the Affordable Care Act. There’s a way to
go, but millions of more people are covered now. There are problems,
there’s some junk insurance that some states are
allowing people to buy that doesn’t really cover them
when they really need something. There are problems
with deductibles, there are problems
with co-payments. We would like to see the
candidates be very specific about how are they going
to address those details in what they propose to do.>>Amy Gutmann: So, we have
some, our own views in the book, which come but ultimately,
we want to make sure that everybody has basic
healthcare coverage. It is a right, not a
privilege that if you suffer from insulin dependent
diabetes, you should have access to affordable insulin. And in this country that
isn’t true right now. [Applause] It’s just not true. The same thing is true
for asthma patients. I mean the idea that asthma
inhalers now are scarce commodities because some
people can’t afford them is unacceptable. So, but that, what that means
is any program that builds on the Affordable Care
Act and enables everybody in this country to
have basic healthcare at affordable rates is
something that we would defend, and I believe from everything
we’ve seen in the polls, a vast majority of
Americans would defend it. So, with regard to the candidates we should
hold their feet to the fire, and for those who want to
— we know that the repeal and replace movement
had no replacement, and now with the
Democratic candidates, we ought to ask ourselves,
and them, okay if you’re going to scrap the ACA, how are you
going to enable any fraction of the 160 million Americans who have private employer
healthcare coverage, who want to keep it, how are you
going to be sure that they have as effective healthcare
coverage? And for the ones who want to
leave their employer coverage, because there’s some employer
coverage that isn’t effective, there should be a
public option for them, it should be for all of them. That’s and we also think that
Medicare should be authorized to negotiate drug
price controls. They’re the largest [Applause]
they are the largest payer of prices of drugs
and treatments, and we are the only
advanced society that doesn’t allow a government
payer to actually look at the effectiveness
of different drugs and judge how much
is worth paying for.>>Jonathan D. Moreno:
It’s really some kind of insanity we don’t do that.>>Amy Gutmann: It is really. So, let me give you
an example that, of why we think the title is
appropriate to so many things where we’re facing in healthcare, all
of us are facing. So, our university is the home, as several other
universities are, of great discoveries
in immunotherapy. And they are saving lives,
perhaps the most famous case is that of a former 7-year-old, a
girl who is now 14-years-old, she was 7-years-old
on her deathbed, her name is Emily Whitehead. Tom and Kerry Whitehead,
her parents, searched, she was all traditional
treatments, didn’t work, they searched for an
experimental treatment, they found one at the
University of Pennsylvania, and at Children’s Hospital, Carl June had discovered
this treatment for acute lymphoblastic
leukemia. Emily is now a cancer-free,
14-year-old, and which is, and she’s become a
spokesperson with her parents for access to this treatment. Now, this treatment now can save
the lives of children as well as adults, saved the live now
of hundreds maybe thousands, but it’s a very expensive. Yet, it is by every measure
cost-effective; it saves lives. And there are other things
that are very expensive that don’t save lives, that
there are many treatments that we get that we’d
be better off without.>>Jonathan D. Moreno: So, we
believe in access to healthcare for all, we believe in really
improving our public health system, and we think, and this
is what Amy was addressing, basic science needs to
put be pushed forward. We need to work on basic
medical science [Applause]. We, the NIH and the NSF have
been constantly under threat for the last few years,
it’s a terrible mistake. A good example that I’m
particular to, sickle cell. So, sickle cell, first of all many sickle cell patients
are not getting adequate care, that is theoretically available
now, they should be able to get, particularly after
the pediatric period. That transition is really
tough for sickle cell patients, and in many cases, they are
really unable to function because of their crises. So, we’re not doing that well. We also though have really some
great opportunities in terms of CRISPR, the acronym
everybody knows now. There are more than a
dozen clinical trials for a sickle cell. It could be curative. So, we have to be able,
you know, we can walk and chew gum at the same time. We have to do both. But it does require society
taking a serious look at our needs both in terms
of access to healthcare and public health
in the one hand and pushing forward the
medical science on the other; that can be a game-changer
for so many people, and it can be tremendously
cost effective if it works.>>Andrea Mitchell: How do
we deal, as bioethicists, how do you deal with situation
on reproductive health in the public health sector? Where religious restrictions
have changed the way the State Department, for instance,
deals with population issues through the United Nations,
as well as the gag order which is now being litigated
from the Ninth Circuit decision? These are tough questions,
but how do we as a society deal
with that when?>>Amy Gutmann: So, we talk
about stem cell research, that I think it’s a great
example of something that was once incredibly
divisive, and there’s now large, not entire, but large
bipartisan support developed for stem cell research. Why? Because people like
Nancy Reagan, and others, had people in their
family who could benefit from the consequences of developing this
kind of medical care. So, things that were once
really controversial, when both prominent people and most importantly the
American public recognizes and gets engaged and really
pushes to have it move forward, that’s when we really
see progress. Most of us easily forget, and some of you weren’t even
born then, but for those of us who were alive when Medicare was
passed, all the same arguments; it was a communist
plot, it was socialism, the same thing with
fluoridation. We talked about fluoridation
in a town near where we both grew up, in
Newburgh, New York, I was, my hometown, which was
quite a conservative town, I heard that it was a communist
plot to fluoridate our water. Well, guess what? Student, you know children’s
caries now have been, you know, are so much less than they
were before, a doctor, a dentist in Newberg said
that when he saw a child with a mouth full of cavities,
he knew that child didn’t grow up in Newburgh, New York. And it took eight years before
New York City, with a coalition of the most famous pediatrician,
Spock, and Dr. Spock, right?>>Jonathan D. Moreno: Yeah.>>Amy Gutmann: The
first doctor Spock.>>Jonathan D. Moreno:
Not Mr. Spock.>>Amy Gutmann: Jackie
Robinson, Eleanor Roosevelt, it took 8 years before
Robert Wagner, who was known to be a very cautious New York
mayor, he passed fluoridation. So, while there are some issues that produce these
horrible deadlocks, and almost every issue
produces them in Washington now, if we get engaged,
we can change that. And only if we get
engaged will that change. And the fruits of modern
medicine are worth, you know, are worth are struggling
for them. And at affordable rates.>>Jonathan D. Moreno: And they’re often
unanticipated good consequences of letting the science
move forward. So, in the in the case
of embryonic stem cells, that led to the use of what
people sometimes call skin cells, that have
been made pluripotent in the laboratory quite
similar to embryonic stem cells. That helped also
to calm the debate. The case of water fluoridation, people didn’t realize how
important healthy gums are to health 40, 50 years ago and that has been proven
out over the years.>>Andrea Mitchell: With some of
the technological advances, A.I. And everything else
that’s happening, what are the biggest issues
that you see to each of you? And then we’ll love to bring
in the audience for questions. The biggest issues that
are new challenges that you as a philosopher have
to think through?>>Jonathan D. Moreno:
I’m obsessed at the moment with what are — and
this is the sort of, this is a very wonky
term, but I use it — what scientists call
cerebral organoids. So, these are a little
bits of cerebral organoids, little bits of brain
tissue, that in culture, in the laboratory can be
cultured, and they grow into lentil sized structures
that recapitulate some of the ways that our brain
cells talk to each other. That is an incredible model
for some, for example, for some of the mental illnesses
for which the well is dry; we don’t have really good
significant improved therapies for people with schizophrenia,
for example. That is terrifically promising. So, that’s very exciting. Some people will find
it creepy, but you know, there is there are some problems that neuroscientists
cannot address.>>Amy Gutmann: You should say
about the mouse with the ear.>>Jonathan D. Moreno: Well,
so, the right, about 15.>>Amy Gutmann: Just
to give you an example.>>Jonathan D. Moreno: No,
it’s a good, it’s a good point.>>Amy Gutmann: Creepy,
but creepy good actually?>>Jonathan D. Moreno:
About 15 or 16 years ago, when a colleague at Stanford
proposed to put human cells, brain cells in mice and
then there was, for purposes of trying to find solutions
to some terrible diseases, and then there was a picture
that went on the Internet of an actual photograph
of a laboratory rodent with a human ear
growing on its back. And people were creeped out. Why was that being done? Well, understandably, but that
was being done because children and accidents who who lose their
ears could have a transplant. If this were to be successful in
such a way that they wouldn’t, their immune system
wouldn’t reject it. So, let’s try to understand
what’s going on here; we need to kind of catch our
breath on some of these things. I’m a big science-fiction
fan, ask anybody in my family, I’m totally obsessed
with science-fiction. Sometimes it can be very
eye-opening to think about some of the imaginative ideas that science-fiction writers
have, I love that stuff. At the same time, it’s
not only not science, it’s not science fiction. Science is only in the
case of the stuff we talk about in the book, it’s also about improving the
quality of human life.>>Amy Gutmann: So, this is
why we wrote the book together; he’s a science fiction fan, and I like Italian
neo-realist films, right? I like to be very pragmatic. So, like my answer to your
question are two things that I think are real very
different the future, in my, you know, realistic
hope for the future. One is that we get cost
controls that are reasonable, so that the great
new technologies, like immunotherapy, like the
new brain science discoveries, can move forward. Because only a good
science partners with good ethics
does it move forward. There are critics of bioethics who think it’s putting
the brakes on science, that is precisely wrong. What good ethics does is
enable science to surge forward because the moment
something like Tuskegee, or the Brooklyn Hospital
— I was born in Brooklyn, so I really identify —
happens, big brakes are put on. And it happened with gene
therapy at the University of Pennsylvania,
with Jesse Galesburg. The brakes were put
on for a decade. So, that’s one thing that I’d
love to see surge forward. The other thing which I just, we focus on in the
book very early on, is we are experiencing something
like the tragedy of the Commons with regard to public health and
mental health in our country. We need to invest more in public
health and in mental health. N [ Applause ] n and when we do, because we
will do it the way, you know, smallpox vaccine saved over
50 million people’s lives. China put a Public
Health Initiative in for the largest
cause of mental illness, which is iodine deficiency
disorder, and save tens of
millions of lives. The tobacco control programs
that we put in more recently, over six years have saved
an estimated 22 million people’s lives. So, the context, we need to,
we talk about nudging people to do the right thing, I
think whether we like it or not we’re being nudged. I am still furious over the
fact that every time I went to the supermarket with
my child, when you check out you have to check out and pay all the sugar
loaded candies were there. Which by the way
appealed not just to her, but to me because that was
the environment I grew up. And now you don’t have to go
to the supermarket, I suppose, but it’s still, it’s not
only in supermarkets, and it’s all the stores. So, we’re being nudged,
the question is, I call that noodging
rather than nudging, you know the bad kind — it’s
a cultural thing [laughter] — but we want to be nudged
in the right directions.>>Andrea Mitchell: With that
I want, I just could listen to you two forever, but let’s
bring some of our audience in. There are microphones set
up, and please get in line. Yes ma’am?>>Audience Member: Tricky
two-part question; one for each. The first relates to
80% of Medicare is spent in the last year of life. Okay, when Reagan was
shot, I can say now, it’s not a HIPPA violation, I
was a nurse for James Brady. I was a nurse for many people
with congestive heart failure, chronic renal failure, on
respirators, and I try and tried to tell the families
say, enough, enough. And then I was lucky enough
to work at the White House for Reagan on health policy. And I made the mistake
as a summer intern of saying only Barbara Bush
can have this discussion with our nation and look
what happened last year; Mrs. Bush made a
decision enough is enough, I’ve had enough medical care. And until this nation has an
honest discussion that 80% of Medicare is spent in the
last year of life, you know, we have to say no to something. Second question is
mental health. I just moved back here
from Philadelphia. We stole Vincent Price from
you, from, to Duke, but anyway, you do great job in
Philly, Dr. Gutmann, I have the highest respect for
you, but Penn does have one of the highest rates of suicide. So, in Britain, they have
heads together, you know, an initiative with
the real family because they noticed
all their charities, their mother started,
you know, veterans. So, the mental health question
for dr. Guttman, the 80%?>>Andrea Mitchell: Thank
you both, for both questions, those are tough questions.>>Jonathan D. Moreno:
You know, there was a, part of this is the way that an
end-of-life care is understood by people, and the media have
something to do with that. I love the media, nonetheless
the way that people have come to understand through film and
television what it is like to be on a ventilator indefinitely,
and how many people actually get out of the ICU having had a
heart attack and so forth. There was a really great
paper that was published in New England Journal of
Medicine about 20 plus years ago by a Harvard medical student,
took a year off to work for a TV doctor show,
and he wrote a paper for the New England
Journal of Medicine which he compared the rate
of successful departures from the hospital on
television having, for somebody who’s had an MI,
and a heart attack in the ICU, as compared to the real world. The epidemiology of
myocardial infarction and TV doctor shows
was the title. It was way over 80%;
by the end of the hour, you know, you’re doing great. Well that’s not always true. So, I think it does take the
culture a little while to catch up with the technology,
and I think we are doing that right now, and your
illustration the story is a fantastic illustration of that.>>Amy Gutmann: So, on mental
health, we had at Penn a year where we had a series of
really tragic suicides. And in the context of a society in which there is a mental
health epidemic I know that term is used too
often, but it truly, if you look at the rates of you
know mental health problems, serious mental health problems,
and the increased rates of suicide they’ve been terribly
troubling over the years. So, what we did was we got a
group of students, faculty, experts in mental
health at our hospitals, really terrific people,
to do a 360, and we now have we’re the
only Ivy plus institution that has a chief wellness
officer for the whole, and we have we’ve totally
reorganized our counseling and psychological
services; we have posted on our website wellness at
Penn with all the resources; and we really took ownership of
the issue, much as we advised in the book we have to do. And it was amazing to me that
last year for example when I met with the student groups who
really care a lot about this, and I asked them, so, after I
asked them direct questions, I said just tell me what
you’re feeling about Penn, they said there’s been a sea
change from their freshman year to the senior year because they
really feel the institution cares about their mental
as well as, you know, physical health and well-being. So, I think that’s what we have
to do, and we also have to, as citizens, try to find ways of making sure our public
officials put the funding into mental health. It ought not to be stigmatized. The estimates are a quarter of our population has
mental health issues, and these are illnesses like
any other that we should own, and we should feel that
people have a right to care. [Applause]. Thank you.>>Audience Member:
Medical care is expensive and in a national healthcare
system, there will be limits to what that system can afford. In other countries, the
government set limits as to what patients will get at
certain points in their life. In this country it seems
like the legislators and policymakers are developing
a system where they put that decision on the provider, thus straining the provider
patient relationship, instead of saying something
like you’re 80-years-old and you and you are in [inaudible]
kidney failure, you can’t get dialysis anymore. So, what do you think
about that, those policies, and do you think the government
needs to step up its side of making decisions in
terms of healthcare?>>Amy Gutmann: So, that the
choice, there are other choices between not just
those two choices. In other words, think about
it, we have to wrap our minds, we spend twice as
much per capita as any other advanced society. I mean these are very
innovative societies, these societies don’t
have; Germany and Switzerland don’t
have single-payer systems, and we can actually, we’re
paying up, we’re coming close to 20% of the GDP; we’re at
between 18 and 19 percent and it’s just going up. So, there are ways to
enable people who need care, need end-of-life care as
well, to get it and reign in the prices of
treatments and drugs. So, you don’t have to say when you’re 80-years-old
you can’t get this. There are many people, I
mean I have friends now who are 90 going on 100, and they’re incredibly well
functioning and we write about in the epilogue to
the book about a dear friend of mine who’s about to turn 90,
who’s the survivor not of only at the Holocaust but of
three different cancers, and was on a very, very
expensive drug among others, Herceptin, which is a
kind of miracle drug. We don’t have to,
the alternative to what we’re doing now,
which is unaffordable and unacceptable,
it’s inequitable, is not to tell people after certain age you
don’t get a treatment. There are other ways
of doing this. And other societies
have done it. Not, I mean, our politicians like to use the National Health
Service and what they’re, the austerities that
they’re going through as the negative example. There are many positive
things to say about it, and some negative things to
say about it, but they don’t like to point to Germany, for example which has
very low infant mortality, very high life expectancy,
and half the cost per capita. And very high innovation.>>Jonathan D. Moreno: We also
have a default in our system to gadgets, to technology. So, I often like to tell
young doctors in training, it’s not that you’re
stopping the caring, you might be withdrawing
some treatment, but you continue to care. And and that is often what
people want near the end of life, they don’t necessarily,
it’s not that we have to translate every gadget
into some form of care, the care is a human factor
not a technological factor.>>Andrea Mitchell: We have
time for one more quick question and quick answer, and
then we have to wrap up.>>Audience Member: Comparing
U.S. Healthcare outcomes with those of other developed
countries in relation to cost, aren’t their societal factors
such as gun violence, poverty, and racism that lead
into healthcare costs and poor outcomes
that are not included in the other country statistics? How can we improve healthcare
outcomes and lower costs without addressing these
societal [inaudible]?>>Andrea Mitchell:
That’s a great question.>>Amy Gutmann: Right, we can’t. We cannot. [Applause]. And that’s precisely
why an early chapter in our book is all
about public health. Because you, two big
things about healthcare; one is that the under investment in public health hurts
disproportionately lower-income, and middle-income, and
minorities in this country. We’re talking clean water, the
availability of infrastructure, [inaudible], lead-free paint,
think about what’s going on in New York City right now. So, Public Health is
incredibly important. The other fact about healthcare
is as we have runaway costs of healthcare, the
single biggest, the single biggest problem
that that creates outside of healthcare is it
starves public education at the state level. Because states have had their
budgets being drained away into unaffordable health care,
away from public education. And that of course also
hurts just those people that you spoke about, and
that is another difference between our society and
Germany, for example.>>Jonathan D. Moreno:
Poverty is a huge risk factor for poor health. And so is inequality, it turns out that there’s some really
interesting neuroscience that shows that if you live
in an inequitable society, that you tend to be more
stressed, and depressed. Inequality is a source
of mental illness. [Applause]. Whether you are poor or not.>>Andrea Mitchell: And then
we think about nutrition, we think about all the other
issues, and environment, climate change, and aside
from lead [inaudible], Newark, New Jersey right now but what is
going on in terms of pollution.>>Jonathan D. Moreno:
Climate is an enormous factor in the future of Public Health.>>Amy Gutmann: But
there is a way forward, and I think it’s
really important for us to recognize these
problems and then realize that all the progress that has
been made would not have been made had the American
public not mobilized. There really, we can’t depend
on the public, you know, public officials for doing
any number of the things that are we need to be done
unless we really hold their feet to the fire, take
ownership of it ourselves.>>Andrea Mitchell: Well we’ve
only scratched the surface, but I just want to say that
this book is, it’s philosophy, it’s obviously ethics, its
science, its narrative, it is just a wonderful book. And it should be a primer
I think for all of us in an election cycle
and in life. So, I just want to thank
you I’m so grateful.>>Amy Gutmann: Thank you. [Applause].>>Andrea Mitchell: Amy
Gutmann, Jonathan Moreno. Everybody Wants to go to
Heaven, but Nobody Wants to Die.

Leave a Reply

Your email address will not be published. Required fields are marked *