7 of bioethics, what centers would you mention besides Hastings? 8 CAPLAN: Now? 9 SWAZEY: Historically and now.

Transcription

1 page 1 1 November 21, Acadia Institute Study ofbioethics in American Society. 2 Interview #2 with Arthur L. Caplan, Ph.D., Director, Center for Bioethics, Trustee 3 Professor of Bioethics, and Chief, Division of Bioethics, University of 4 Pennsylvania. The interview is being conducted by Dr. Renee C. Fox, Dr. Judith 5 P. Swazey, and Dr. Carla Messikomer, in Dr. Fox's apartment in Philadelphia. 6 SWAZEY: If you had to focus on a few centers in terms of looking at the institutionalization 7 of bioethics, what centers would you mention besides Hastings? 8 CAPLAN: Now? 9 SWAZEY: Historically and now. 10 CAPLAN: Penn State was important. It was a place that did medical humanities early, and 11 had a certain vision of what medical humanities is, as opposed to what medical 12 ethics was going to be. When I came into the field, I encountered Al Vastyan and 13 Dan Clouser. I'm not sure I agreed with what their vision of medical humanities 14 was, but it was a vision that was interesting. It didn't strike me as completely 15 plausible to try and synthesize art, music, history, philosophy, religion, behavioral 16 aspects; it was almost too much. But I understood something that I'm not sure 17 people at Penn State even did. Part of the reason they set it up the department the 18 way they did was they were trying to literally do humanities in a setting where the 19 medical school was nowhere near the rest of the university. So it was a structural 20 feature; it was driven less by an intellectual vision than a necessity. Same thing 21 for UT Galveston: very similar kind of programs, similar location, far from the 22 rest of the school, I mean, hundreds of miles. An important program. Ron 23 Carson and Harold Vanderpool, were people that I met when I was just coming

2 page into the field. I think the UT Galveston Program produced scholars that sort of wove their way into bioethics. Other institutions that were important? Well, the journal, Perspectives in Biolo and Medicine was important although not read by 27 many of the philosophers. I happened to read it because I had the biology FOX: 32 CAPLAN: 33 background, so I came from a weird direction. I was interested in reading it to find out that there were biologists who had humanistic thoughts, which was unnerving to me. I didn't realized there were going to be any others like this. For example? In terms of the biologists. Well, there was Landau, himself, Leon Kass and Roger Masters and Clifford Grobstein. E.O. Wilson had some early papers in Perspectives place; I am very 34 interested in early sociobiology writings. So I looked at those and thought they 35 were all interesting, sort of an anti-reductionism even. That journal was a voice that we could sort of go to. Another weird journal, which no one even remembers anymore, was Zygon? It was trying to bridge religion and science, hoping, in fact, that they could reconcile the two. I never believed this was possible. I think religion and science actually are at each others' throats, fundamentally, about the way the world is. But, they hoped to do what today would be called a Darwinian foundation for religion, or something. Most of the stuff in there was pretty bad. 43 FOX: Who were the movers and the shakers? Anyone in particular? 44 CAPLAN: The editor, I'm trying to remember his name. What was his name? They actually

3 page invited me to a retreat in New Hampshire at one point which was pretty weird because, it was like, you know, 400-year-old people and me. (Laughter) It was 47 very odd, but as goofy as they were, they were trying to do something interesting, which was to at least confront religious and scientific views. And that was an influential journal-structure type thing because it was the place you could go to see people try to talk. The religion people had no understanding of science, and the scientific people all thought the religion stuff was goofy but they tried to be polite to one another in these pages, which was unusual because they normally 53 just ignored each other. 54 FOX: Would you put your former Center, Minnesota, on this map? 55 CAPLAN: FOX: 65 Later. These were early institutions, ones that then get influential, sort of building along. In Chicago, the medical ethics program that Mark Siegler created is a very important place, for lots of reasons. It represents a shift to the clinical. It represents the move of physicians to take charge. You'll hear many times in your interviews about the battle between doctors and non-doctors. Whatever Arthur Kleinman thinks, he's battling with the social sciences versus everything else. A much more vicious battle was engaged in by Mark when he directed the Chicago program toward physician-driven ethics. That still lingers in the field to the present day in bioethics but it was really Mark's program that did it. I'm sure younger people now are saying that it is interesting that the people coming into the field, who know bioethics as a third generation, includes a

4 page CAPLAN: significant number of physicians. They do, but not in the way Mark thought they would. Mark thought they'd be clinical types. I used to make a bad joke to myself, I rarely made this in public, which is unusual because, I'll make almost any bad joke in public. Mark's vision was that clinical skills would drive an understanding ofbioethics. Today's physicians believe that health services research, that outcome study, that a group community focus is what you do in medicine. It's very different...they wouldn't even have the time of day for Mark, to tell you the truth, because he is so clinical. It's not that they don't see patients, but their intellectual focus is very different. 75 So it's a different kind of doctor coming in today. It's a different world from what 76 Mark was doing. It's very different. His vision was closer to Ingelfinger, to the 77 great tradition of clinical diagnostician, of the art of medicine; you had to have FOX: 82 CAPLAN: that empathy and time with patients. It was irresponsible to just sail in as a philosopher or somebody from the outside and say, "Well, I think this and I think that." Did Mark Siegler have any kind of a relationship with Ingelfinger? Not that I know of. I'll bet that all of Mark's mentors were trained by or interacted with Ingelfinger extensively. I don't know that. I'll make a sociological prediction about an invisible college there. 85 SWAZEY: We'll find out. 86 CAPLAN: Yeah... (laughter). Alvin Tarloff, who wound up going to the Kaiser Foundation,

5 page was a close mentor of Mark's. I bet Tarloffwas a friend oflngelfinger's, they had to be. And Sam Thier was wandering out to Chicago at different times to help them organize some of their clinical stuff; when he was here at Penn. There's a figure that no one remembers but I think was influential about the time of Mark 91 Siegler. He didn't have an institution or anything-- Robert Morrison. I think he played an interesting role because he was another grand old man, clinical, Yankee doc-type. People paid a lot of attention to him. He really had influence. I can't 94 remember, but I think he was tied in closely with the Rockefeller Foundation, with FOX: funding sources. Yes, he was an officer of the Rockefeller Foundation. 97 CAPLAN: So the institutional thing was there, he became a person who was influential both 98 because of his ideas and because he had contacts to the foundation world, and so 99 Hastings could get money, or others, if Bob liked you. So Chicago becomes a crucial program in the 1980's for bringing physicians in. Many, many physicians now in the field, not of Glenn McGee's generation but my generation came through that Siegler program. Steve Miles, who was at Minnesota with me, was a Chicago product. John Lantos and Dave Ducas and John Lipoma; there are just lots of these people running around. 105 FOX: 106 CAPLAN: 107 FOX: They're still grouped around Chicago. A lot of them are still in the neighborhood. Lipoma is still there. Lantos is still there.

6 page6 108 CAPLAN: FOX: 111 CAPLAN: FOX: 119 CAPLAN: FOX: 122 CAPLAN: Lantos is there. Ducas left, went to Michigan. Chris Cassell actually counts here too. She became head of the general internal medicine division. Although interesting gossip to record for historical purposes. Mark and Chris did not like each other. I'm not sure why. I think Chris was more the political doc and Mark was more the bedside doc. And there was something in that culture that's at a level of refinement that I don't even understand. I think they just had two cultures of medicine; there was sort of the political side and the sort of internal medicine culture. Other institutions, I'd have to say Seattle with Al Jonsen. I think that it's not.... What about Al Jonsen before Seattle? I was going to say this: I think Al was a one-man institution and it didn't matter where he was. Yes, that's why I asked. So at UCSF he had influence, at Seattle he had influence. And you've seen this little history of bioethics he wrote, from the Seattle Dialysis Center to today. Well, I think that's all nonsense. He happened to be in Seattle. There wasn't anything bioethical going on in Seattle, but there were interesting events taking place. 127 SWAZEY: In terms ofucsf and Seattle, you're saying that as qua Centers CAPLAN: They are meaningless. Al is the one-man California figure. Hastings is trying to

7 page FOX: 136 CAPLAN: FOX: CAPLAN: FOX: CAPLAN: 149 FOX: get Al, at different times, to set up a west coast branch. To figure out some way to get a presence in California. Al is clearly aspiring to do that on his own and turns out to be not cooperative. This is an eighties phenomena. But he never brings off the creation of an institutional base. To this day, for reasons no one can fully understand, the west coast of the United States remains, relatively speaking, bioethically barren. Bernie Lo... It's probably not until the 1990's that Bernie succeeds in setting up a small what we would call institutional presence at UCSF, but that's not until really three or four years ago. Until then there's nothing. There's people. Imagine this. Alex Capron has never been able to set up a thing at USC. He has this little Center but it's not really a Center, it's Alex. It's sort of interesting too because the brilliant sociology that was housed at UCSF was in the nursing school. Hyper-medicalized there way more than is often imputed to the east coasters. UCSF, I mean, just hyper-molecular, hyper-reductionistic, hyper-medicalized. What does Al Jonsen represent, just in terms of this institutional overview you're giving us? In some ways he's a Commission man; he represents the "bioethics goes to Washington" man. Yes, he is a forerunner of that. And in addition, he'll always have around him the penumbra of a Jesuit, even

8 page CAPLAN: FOX: CAPLAN: FOX: 168 CAPLAN: 169 FOX: 170 CAPLAN: though he isn't a Jesuit any more, because he officially stands for, in the eyes of someone like Morris Abrams, somebody who is the incarnation of the learned clergyman. Yup. The casuistry tradition which is AI, which is Catholicism secularized or something. Yea, AI was an early model for something that takes a long time to happen, which is the Commission man. That's what he is. He has more influence in Washington D.C. than in Washington state. I would bet that people couldn't recognize AI in Washington state but they'd know him in Washington D.C.! Some of that is not unconnected with his years at Georgetown. In his years as a priest, for example, he felt that the President of Georgetown was a very intimate colleague of his. So he was tied into that Washington circle. I've introduced AI a couple oftimes as the Forrest Gump ofbioethics. He's been present at all these different Commissions. You look back and he's in the artificial heart thing and on the human experimentation thing and he's on the President's Commission thing. I mean everywhere you turn, he's kind of in the background as if he was inserted in, you know, standing next to somebody or other. There he is! The reason I ask you that is because he is a very intelligent and a very clever man. Yup. But I don't think he's a terribly good theologian or a terribly good philosopher. And weirdly, his scholarly influence would almost be nothing if he hadn't teamed

9 page FOX: 175 CAPLAN: FOX: 189 CAPLAN: up with Toulmin to do the casuistry book. On his own, probably not, with Toulmin, something happened there and so he has this legacy of sort of reviving casuistry, but I think it's actually Toulmin's voice and less Jonsen. So there's no Center out there. No. There is another program that's of importance and that is Virginia and it's John Fletcher. Fletcher is doing something which I have only recently come to understand by watching Jonathan Moreno about to go there to take John Fletcher's job. He just retired. Moreno worked part-time at the Hastings Center with me. He is one of the Caplanesque figures that will now go and sour the Virginia program. But, interestingly enough, I've been invited to Virginia a couple of times, so I've seen snapshots of it at different times. There is an institutional base at Virginia. Childress, Fletcher, a guy named Walter Wadlington in the law school, Richard Bonnie in the law school. There's a physician whose name I always forget in the medical school, who's a very influential fellow. So they have people and a subject. But it's very interesting. Virginia, under John's leadership, did something unlike any other Center. It went to grassroots bioethics education. It tried to outreach to the community. Chapel Hill did too, didn't they? Not this systematically. This guy, Fletcher, was not a prophet in his own land. I've only come recently to understand that the medical school deeply resented John because he was pushing hard to put bioethics into hospitals and nursing

10 page FOX: CAPLAN: 209 FOX: 210 CAPLAN: 211 FOX: 212 homes and other health care institutions around the state. He also spent a great deal of time at the NIH. He was the house ethicist there for a long time. Virginia, as a program, I would say, was a loose collection rather than a structured institutional base. Its individual members had tremendous influence. It did have a training program. Courtney Campbell would be an example of someone trained in Virginia. Mark Hanson, who's currently at the Hastings Center, is a Virginia product. They are the place that kept the flame of religious studies influence alive in bioethics. However, that being said, it was more a loose collection than it was a really pulling together a structured institution, because John took it off campus. If you went to Virginia you'd be startled. You could go to almost any little hospital and you'll find somebody went through their intensive course or spent time with John learning to do bioethics consults. John starts the Society for Bioethics Consultation. John has an interesting history because he was an Episcopalian priest who had a church in Washington D.C. that was enormously influential. Sargent Shriver was a person who attended John's church. I didn't even know that. We will interview John in depth. He should be. Because he has undergone many metamorphoses. The religion thing remains; I didn't know about the outreach to the community program, but it is part of the

11 page CAPLAN: FOX: CAPLAN: FOX: 224 CAPLAN: pastoral role. His early formative years are reflected in what he does. He sociologically is still ministering throughout his entire bioethics career. It's absolutely true. That's what he is doing. He is spreading the word. He is proselytizing. The only other place I can think of that would be a wonderful place for that kind of thing would be Emory. We need a Southern milieux to do that kind of thing. I understand. The flavor of bioethics in that Southern culture is Protestant, is ministerial, is proselytizing, is very different than the Northeast type thing. The Northeast type thing is rabbinic, it's Talmudic, it's Yeshiva-like. And these guys are... Caplanesque. Right. Or it could be Irish Catholicy in a sense ofbattles about church doctrine, that influence is there too. I mean, there's Catholic-Jewish type things in the Northeast, but the Southeast, with Virginia as the example, definitely reflects its culture in ways that we just commented on. 228 FOX: CAPLAN: Within this framework that you're sketching out, some people, even though they're not one-man institutions like AI, are like Jim Childress, who is not just an important figure but is also a kind of institutional figure that is not summarized by just Virginia... But you know what's interesting there? Childress is an important figure and it

12 page FOX: 244 CAPLAN: 245 FOX: isn't just summarized by Virginia because he kept the ties to Kennedy. Childress is as much a Kennedy Institute guy as he is a Virginia guy. Part of the reason is he didn't have the intellectual community to talk to as a scholar; you know, his background is Quaker. I think he very much does believe in consensus and the values of consensus and so on. I'm speculating, he's never said this to me, but I don't think he felt quite intellectually satisfied just with the Virginia-type operation. He was drawn again and again and again to Georgetown. He teams up with Beauchamp. I saw him many more times at Georgetown than I ever did when I went to Virginia. He wasn't there. So, yes, you're right but I would almost put him as half-virginia, half-georgetown. He's also half religious and half (inaudible) Yea... yea... yea. I've talked to him about this, and said he would do a great service to the profession if he would write a piece about the moral dilemmas that are involved in being in a public role, or having a public responsibility like running a commission. And I'd like him to write about bioethics from the point of view of somebody who's now a figure dealing with policy, as compared with the way he writes when he writes in religion journals, where it's a completely different voice. And about the kind of real tensions that are involved in those two roles. So he really is quite a radiant religious figure, but when he puts on his cap either to do principles or to write about the transplantation commission that he ran, it's a

13 page CAPLAN: FOX: CAPLAN: FOX: different person. That may be, having immersed a little in the Quaker culture through my kids' school; it's a Quaker school. Quakerism is kind oflike that. It's personalreligious, it's very individual religious and not much in groups. You can go to a Quaker meeting discussion of should we build a new building and even though there are deeply religious Quakers there they don't talk that way when they're together. So I'm not sure... He uses rather standard Protestant theological language when he writes in religious journals. You wouldn't necessarily know that he was a Quaker in terms of the church language he uses. But anyway... Other institutional things of importance in the mid to late eighties. Park Ridge becomes of interest, I don't think of major importance but moderate importance. Not major because of a couple of things. It has a mission. It wants to bring religion explicitly in, but, it never finds a publication vehicle that succeeds. Its journal, Second Opinion, is not widely read or quoted. It's never actually overcome this problem of its outlet. The book series that they did, tend to be not widely distributed. My estimate or my judgement would be that people know Park Ridge is there and they know that it's trying to do a particular mission but that it never marketed itself to penetrate seriously into the mainstream bioethics dialogue. We are interested in it for another reason, because of the way that it started

14 page CAPLAN: 278 FOX: 279 CAPLAN: FOX: CAPLAN: 285 FOX: 286 CAPLAN: FOX: CAPLAN: through the Lutheran system of delivery of health care and the linking of it so it has the faith and ethics. The best stuff it does actually is things like the recent organ procurement stuff. Or the principles book and so forth... That's been a long time coming. For a long time they weren't doing anything. They were there but you, sort of, didn't know... The whole series that Martin Marty and others did about fundamentalism is not totally a Park Ridge thing, but that is where the Park Ridge thing opens onto the University of Chicago. Y ea...interchanges there. Alright....let's see... other institutions... AMA. You left out Minnesota...(laughter) I'm getting there. I'd say Virginia is older than Minnesota. The AMA has an influence. This Council of Judicial Affairs kind of thing, always viewed with some scorn even to the present day as kind of an apology-for-the-profession type stuff, occasionally fires out an interesting opinion piece or something and taken very seriously by the AMA. The AMA is a lot more complicated. Sitting on the board of JAMA all that time I was struck by the degree to which one can write independent things and have independent thinking; it is more than just a kind of spokespeople for the profession. I think the Council on Ethical and Judicial Affairs was more of an apologist for

15 page FOX: CAPLAN: FOX: the profession in the fifties and sixties, but I actually think a synergy took place and bioethics helped to beef-up that committee and gave it courage. I found my most provocative opinions cited often in Council on Judicial Affairs opinions that would make it into JAMA. "Oh, they actually read that?" They were out of the organization a lot. The problem they had was they really did take on a serious intellectual momentum and then the members of the AMA tried to restrain them sometimes. They would get out of step with membership. I think the kinds of issues they took on, with bioethics being synergist, you can't exactly have a sort of official AMA position on something like "What is life?" or "What is death?" I think that's right. I think they were dragged, at first, into bioethical areas, and some people on the Ethics and Judicial Affairs Council said we should be reading some of this bioethics stuff. And they did and they took it seriously. I actually wrote a review which shocked them. It was a kind of funny, sociological phenomena. About five or six years ago I reviewed their code of ethics and I said, "This is really worth reading, it's very interesting." They were so shocked they keep using it on the back of the book, saying, you know, "Arthur Caplan says, it's worth reading!!" (Laughter)... That's interesting, because if it turns out that a prominent bioethicist, a spokesperson for bioethics, provides an imprimatur of legitimacy for their ethical....

16 page CAPLAN: Absolutely did. They were coaking it and saying it must be okay. (Laughter). They actually worked. If you were into deconstructionism, you can just trace that little event of the placement of this quote on the back of the book. It's the only quote that appears on the back of the code of ethics book that's given to every medical student. It's basically me blessing this! How did that come to be? Why is he doing it?? 323 SWAZEY: It's your early rabbinical exposure!! (Laughter) 324 CAPLAN: That's it!! Thank you! 325 FOX: Yes, because you would expect it to be the other way around. 326 CAPLAN: Sure! Exactly! 327 FOX: The AMA would speak approvingly of your work rather than CAPLAN: So it's just funny. It almost made me blush when I first saw this. I thought, this is 329 papal. So now the Pope has blessed our work and we may go forward. I mean, I 330 said it but I wasn't trying to bless it. It was just a comment. 331 FOX: Okay, that's interesting. 332 CAPLAN: Modem institutions of importance. Minnesota becomes an important place 333 because it's there, for the first time I think in the eighties, that Centers begin to 334 move to tie-ins to medical schools as a structural feature; although bioethics is not 335 tied really, in a structural way, to medicine. Teaching is not going on. You've 336 had this lament forever: they won't let me teach in the medical school. I think 337 that's true up until about When Minnesota starts, it's put in the

17 page FOX: 342 medical school; its mission is to try, among other things, to teach medical students. I'm not saying no one was teaching medical students but structurally this joint is housed right there. It's a very interesting study that I don't think we can deal with, is where was ethics taught in the medical school before bioethics? One of the places was 343 psychiatry. 344 CAPLAN: I understand that. I think there are waves of--who can save us from our FOX: 347 CAPLAN: 348 mechanistic, fiendish, de-personalized...! mean, science goes through. But this was an explicit decision. Minnesota was an explicit decision too, and it had structural features like my being an equivalent of a department chair. It was very clear that our courses had 349 to be passed with grades. If you didn't pass you had to take them again. Teaching bioethics, I think, prior to about 1985, meant an elective course or maybe a mildly required course, but certainly if you failed it you weren't going to go back and repeat it. That changes with the Minnesota-type model, which is, "this is serious". 353 FOX: Did you bring that to them, or did they bring you in to head the Center in order to 354 do that? 355 CAPLAN: They probably were ready to do it, to tell you the truth. But I said, look I'm not doing this old style thing. If we're doing this, we're going to do it as a serious thing and people are going to be evaluated. If I write a note saying I don't think Mr. X has mastered what he needs to know about the core value of this discipline,

18 page he's going to get that in his evaluation and that's going to stay there. I didn't 360 write that too often but I did write it once in a while. We institutionalized rounds 361 and things like that so they were beginning to just appear routinely. 362 END OF SIDE (CAPLAN, INTERVIEW 2, TAPE 1) 363 CAPLAN: Minnesota becomes a place where the first, what I would call, current turn toward 364 empirical synthesis is made. I'm bringing that and I'm certainly thinking, well, 365 bioethics is too ahistorical, bioethics is too asocial, bioethics is too American. I 366 don't know if it's too American but at least it's all-american. (Laughter) 367 FOX: It's going to be recognized as American. (Laughter) 368 CAPLAN: At least it is American and attempts were made to build into the faculty hires 369 people who can do something about that. Broaden the discipline out, to listen to 370 more voices and make ties to other departments. 371 FOX: Didn't you bring in Nursing, too? 372 CAPLAN: Yup. So we actually had crossed the point to the School ofnursing. We had 373 nursing faculty on the Center faculty. I don't even know if they did that before, 374 but it may have been a first for bioethics. The other structural feature or 375 interesting institutional fact about Minnesota is that, I'm going to hate myself for 376 telling you this, you could actually see for the first time Bioethics Centers 377 institutionally beginning to compete with the old line places for the best talent. 378 FOX: Why should you hate yourself?

19 page CAPLAN: It's just someone would say, "I knew they were competing." (Laughter) Of course FOX: 392 CAPLAN: we were competing. We were starting to look to see who could we hire. Susan Wolf was brought to Minnesota from Hastings. That's a very interesting phenomenon. I recruit her. Steve Miles is brought from Chicago to Minnesota. So all of a sudden, there are others of this ilk, but I'm starting to look out there and move talent away from Chicago, Hastings, traditional places of strength in the field. This is serious. As sociologists you must pay attention to this because now we're talking about redistribution of personnel and power within the field. There is another program that deserves a mention here that is doing much the same thing as Minnesota without the social science focus, but it's embedding itself in the culture of it's medical school and institution. That's Case Western. That's Tom Murray's activity. And Stuart Youngner. They are a very good program and they are doing much the same thing, in terms of hiring and looking to see where they can move people to come there. Tom, you know, has got a social psychology background, he's one of the few social scientists in the whole field. He and I overlapped at Hastings and we're friends. We're sort of friendly rivals now in the sense in which I think the Case Program is a good program. I consider that a real, sort of equal equivalent to the Penn Program, almost. (Laughter)... No, actually ours is better. It's a larger program. We have much more strength but it's for a funny reason. Case doesn't have a

20 page FOX: 406 CAPLAN: 407 FOX: CAPLAN: 410 FOX: 411 CAPLAN: 412 FOX: CAPLAN: college to bolster it. We have all the resources of a full major research university. They have a great medical school but it's sort of parlors a liberal arts campus. It was an engineering school so it doesn't have the same sort ofstuff we can bring to bear in the masters program and stuff like that. They have a masters program, and they're in the medical school in a very routine and expected way. Yes, when I've been there they've brought in the chaplains, the nurses certainly... They're tied to the medical school, very tightly. Yes, and then, of course, Case Western Reserve has a very special kind ofhistory in terms of the experimental edge to their educational ventures. Yes. They did their organ-based training and their patient-based training... Intellectually, though, I don't think it's the same stature as your program. No.. no.. Because Tom Murray was a lovely man, but he's not got your political clout or your intellectual stature. Yup... but I think institutionally it's a good parallel type. That model now is very different from the Penn State, UT Galveston model. You know this better than I do, but I don't think the BU Program in Health Law has a particular type integration with the medical school. 418 SWAZEY: Actually, I'm going to be talking to the folks there in a couple of weeks. They 419 don't formally teach as the Center for Health Law and Ethics because the faculty 420 in that program are faculty in the School of Public Health and the Medical School.

21 page CAPLAN: FOX: CAPLAN: 433 That's the other one I was going to mention. The BU program is there but I just wasn't sure how it works. There's a talent thing here; that's what I was getting at. Wendy Mariner, Leonard Glantz, Grodin. Forget George Annas...(laughter). Forget George for a second here. George is doing the same thing I'm doing. He's building a talented pool of people. That's what I meant. He's there as an individual for a long time and Judy's there. Now a program emerges with serious younger talent that you would have expected to see at the Hastings Center or maybe at Georgetown. Now they're at BU. That's what I meant. Isn't there something else? Your program, I know, has Sally Nunn coming on board and so forth. What about this whole other thing that you're shaping into a kind of outreach aspect of it? That's a nineties phenomena. Now we've almost got to Penn, almost. So we've got institutions SWAZEY: BU is a nineties program, that whole law-ethics program. 435 CAPLAN: Although I'd say that some of the talent pool is starting to show up in the eighties. 436 Two other institutions of some note. David Rothman at Columbia has his little 437 program chugging along. It's not of the size of Case Western or Minnesota, but 438 something's going on there, and he's bringing in some younger people to the 439 program. 440 FOX: This is another kind of variable. The program I think is of lesser consequence, but

22 page CAPLAN: are things like David's relationship to Soros factors that get into making it more important than it seems to be? Yes. I hate to say it, but the simple New York City location makes it more important than it is. I mean, it's just a fact of sociology. He has the ear of certain media outlets, certain foundation people, certain persons of influence, just by being in New York. That boosts his efforts and his little program. 447 FOX: Do you think what David is doing is at all continuous with the Bernie Schoenberg 448 tradition? I mean, he has the chair. 449 CAPLAN: 450 FOX: 451 CAPLAN: No.. no... zero. I think Bernie would be disappointed. I do too... okay.. alright. New York also has the Montefiore Clinical Ethics Program ofnancy Dubler. It's a teeny, teeny program. It's a Nancy Dubler, John Arras, who's now gone to Virginia, by the way, along with Jonathan Moreno. They're both moving there. Virginia will become a place of importance in the future, in a different way than it has been in the past. But it continues to be, that's my point, that people are moving there to take over the old guard positions and that program is actually 457 doing well. 458 FOX: So you're putting this against the background ofthe numbers of programs that 459 have basically faded out. 460 CAPLAN: 461 FOX: Correct...correct. Those that renew themselves and go on into the next decade are ones that you

23 page CAPLAN: think... Correct. That's sort of interesting. Others like Penn State still endure but less influential. Galveston is still there, far less influential. I'm not sure anybody could... can you tell me what they're doing? What field? I know they're there. They go on but with less influence. 467 SWAZEY: They are really involved with medicine and humanities. 468 CAPLAN: Yea. 469 FOX: Even there the health and human values thing has more influence than the medical 470 humanities. 471 CAPLAN: Yea. You don't see it the way it used to be. You knew when they were speaking 472 for medical humanities things fifteen years ago. Much less so today. I'm not 473 going to say zero but FOX: No... no. 475 CAPLAN: This Montefiore Program's very important though because, like Mark's program, 476 it is clinical ethics driven. It is the place where this model of the consult begins to 477 really thrive. Nancy Dubler's forte is, much as Mark's was, although he'd kill 478 himself to think it, the bedside ethics consultation. When people in New York 479 City think ofbioethics, they think of Nancy going into a case situation and kind of 480 acting as a mediator or arbitrator to a problem. It affects a whole city's culture, 481 this little program, and is an influence in a lot of ways over one model of what a 482 bioethicist does. It's close to what Mark's is but institutionally it begins to really

24 page FOX: 485 CAPLAN: roll in the eighties too, that's what I meant. So these programs are now... Albert Einstein has that model too. Well, it was the Macklin and Fleischman model. They were doing the exact same thing. I hate to say it, they'd also go nuts if you said it, but they were influenced by the Montefiore program. They'd like to think they did it themselves. I don't think so. I think they were influenced by it. The programs are still there, but my point is, as a sort of sociological observation, these programs--einstein, the Minnesota Program emerging, the Case Western Program emerging--these are institutional bases that are now power Centers or points of influence that are pulling centrifugally against the old Hastings-Georgetown axis, if you wanted to say what "old" bioethics was. Into the nineties programs, this aircraft carrier thing at Penn begins to appear and immodestly starts to take on some of the many 495 functions that Hastings used to do. I mean, it is now the home of the AAB rebellion. The emergence of this idea that there should be a bioethics organization, sometimes viewed as the philosophers rebel, but I don't see it that way. I see it as the professional bioethicists rebel, as a matter of fact, against the old medical humanities model. You have a program like Penn showing up and saying, well, we will do many of the things that older bioethics programs did. We will do outreach like Virginia and the John Fletcher thing. We will do case consultation like Montefiore and Mark Siegler have done. We can integrate social science in a cultural critique. We will look at policy like the Hastings Center

25 page FOX: CAPLAN: FOX: CAPLAN: should be doing but doesn't seem to want to. I don't know where they're going now. Last time it looked like eco-philosophy in the woods or something. We will continue this Minnesota tradition of being integrated in to the medical school. Although a slight shift takes place because Penn moves towards trying to integrate a social medicine--bioethics sort of... You have 30 undergraduates who are doing volunteer work in the Center, so you are getting far more than... We have so many bodies going by now. I used to think the field was a fad; now I think it ought to be stopped as a movement or a cult or something. (Laughter) I'm teaching Sociology of Bioethics both semesters this year. Virtually everybody I'm teaching has had some contact with your Center. They are also studying at the same time they are taking everything in sight. Whether it's with Glenn McGee or David Magnus, they're doing everything in sight that could be done. So we're referring people back and forth. Here's even a stranger phenomena, probably not the most odd thing that you could never think of, but is remarkable to me. The program at Penn succeeds in doing the impossible, it re-integrates back to the philosophy department. It's like whoa!! We run the masters degree through the philosophy department. We actually have appointments for all three of our philosophers in the philosophy department. Arthur Caplan, when the philosophers come here this December, is giving two invited speeches at the philosophy meetings. As medical ethicist not

26 page FOX: CAPLAN: FOX: CAPLAN: 538 FOX: 539 CAPLAN: FOX: CAPLAN: 545 as philosopher. But you knew, you wouldn't have come here if you didn't think you could pull that off. I thought I could pull it off, that is a very appropriate phrase. I THOUGHT I could but wasn't sure but it's worked. Philosophy departments are everywhere, they're always pains in the neck. I've been invited for years to speak at philosophy meetings as a philosopher of science. I've never been asked to speak qua medical ethicist...never. I've given talks over the years many times on the philosophy of biology, all kinds of sociobiology things, theory change, and so on. You want to know the analog to that? When Judith and I are invited to speak nowadays, we are always invited because we're ethicists, never because we're historians or sociologists. Really?!...(laughter)... You don't come as sociologists, you come as bioethicists! Yea! So personally, that may be the most interesting and rewarding intellectual achievement of all. But this doesn't square at all with the reason that you were brought here, and the understanding of what you were going to be, that made our dean decide that this was a major event rather than a minor one. But that never interested me very much. That vision was... alright, if you wanted to have that vision then it didn't bother me. Coming in as cover for genetics or

27 page coming in as police on the Gene Therapy Institute if not an apologist. We do work with the genetic stuff. We have millions of dollars of grants now sitting there to do things with the genetics stuff but I knew that would be just blown out 549 ofthe water. 550 FOX: CAPLAN: I knew that we would get a bioethicist finally, once James Wilson appeared, not just because of money but because of what it was that would represent. Then in addition, I knew that if he met you that you would click. But actually it was the role, the fact that a major work in gene therapy was going on at Penn, and they couldn't hold their heads up and say we don't have a single presence on campus that has any ethical competence whatsoever. You know more about that history than I do. I had this discussion with Kelley and 557 I knew what message he was sending about his hopes and dreams that we would FOX: CAPLAN: have ethics for genes. I kept saying ethics for genes is okay, but I have bigger fish to fry than just running around looking at genes all day. And I told him so. I said, "Look, I think that's a narrow vision." I mean, this is actually funny because this guy isn't used to being told that his vision is wrong. So he's sitting there saying, "What??" I think I actually did say it was stupid, it's not what you want for a bioethicist. That's probably why he liked you, as a matter of fact. Not just because you talked back to him but because you talked "big". Big visions he likes. When I told him he had a little vision...(laughter)... he said, "I

28 page FOX: CAPLAN: FOX: 583 CAPLAN: do??" It's true! He said, "I do??" I said, "Yea, genes is a piece of it." I told him too, "Look, the other thing to do with Penn, we should do outreach and public education." It was very good that he did not care and still said he didn't. But over the time that we've been here, if you ask Bill, if you were to interview him, he'd say, "I can't believe what Art did. He has pushed this thing into some visibility beyond..." But the visibility thing, without cheapening his appreciation of you, this kind of putting Penn on the map that you're doing, at a time when he's doing what he's doing with the health care system and competing for the market share and so forth... But he couldn't have dreamed he'd be sitting there, when he was trying to set this thing up, he thought a big gene push would do it. He didn't know that we were going to be the paratroopers to go in and make the first visits to the places he was going to try to buy, or acquire, or affiliate with. A whole different phenomena, the managed care thing has shifted. Why did he send you in? He doesn't, we just de facto were there first. I always come back to him and say, "You know, I understand you're trying to run a system and acquire things or sell things or do whatever the hell you do. (Laughter) But, you have to keep in mind, Bill, they know us before they know you." We are literally there long before your system is. We get invited to Brandywine Hospital or Delaware Memorial Chronic

29 page Facility or whatever it is. They don't even know what Penn Health Systems is but they know who we are. We're like the Airborne, we show up way in advance. 590 SWAZEY: The Recon Squad. 591 CAPLAN: Exactly. So I say, you've got to realize that you should build to this strength. 592 He's slowly getting it and so are the people on the marketing side. He's certainly 593 pleased that the name is out there. We've had approaches at this point, this is 594 sociologically interesting, from at least two institutions; Holy Redeemer System 595 and Catholic Health System have come to Penn and said we want to consider 596 affiliation. One reason is because you have the Bioethics Center. Bill's in a 597 spasm of delight over this. (Laughter) So in a sense, bioethics has hooked him a 598 fish that he never dreamed of. He thought maybe he'd keep the regulators away or 599 there wouldn't be demonstrators yelling that they didn't want to be cloned. I had 600 a dim idea but he never thought that we would have any influence over the 601 direction of the way the system went. 602 FOX: I think you saw this. 603 CAPLAN: I did. I absolutely thought, this is great! We can use this to buy intellectual 604 freedom. Penn becomes a major player in the contemporary scene for sure. I 605 mean, personally, I think it's THE major player. I'm willing to write that off to a 606 certain amount of immodesty. 607 FOX: We'll see how dormant the others are. 608 CAPLAN: Today too, I think Case is lively and has activities going on and is doing lots of

30 page FOX: CAPLAN: 614 FOX: CAPLAN: FOX: 623 CAPLAN: FOX: 629 work and I think has built up a pretty good group. Chicago has not succumbed to malaise, they do things. Chicago is important too, because of your emphasis incidently, the whole university kind of thing that Chicago is embedded in also. Yes. A lot ofthe names, just as an example, a lot ofthe names you've been talking about at Chicago, who recruits Nicholas Christakis? Not for bioethics, but neverthe-less, it's Chris Cassell. And then, who is one of his bosses? John Lantos, and so forth. There's that much larger configuration, there's a lot going for them. It's still there. Jason Carlowit, this young geriatrics guy that we just had, was a Lantos-Cassell product. They're still putting out people who are definitely talented. I'm not sure I have a vision of which direction BU is going to go in right now. I don't know. George is still a major voice, a very important figure. Georgetown, is it fading away a little? I think it is a little. I think Georgetown is fading, not to the Hastings level but today, in contemporary structure, I'd say it's not got the same punch. Its leadership, interestingly enough, is also dropped from Andre Hellegers and Ed Pellegrino to Kevin Wildes, I think, is the director now. A young guy, nice guy, but that's not the same stature. Those aren't the same figures. Both Hastings and Georgetown have very many ofthe attributes of the charismatic movement with the founder/leaders and the whole business of the

31 page CAPLAN: FOX: CAPLAN: classical thing, the succession of the founder/leaders. Dan Callahan is certainly a case and Georgetown is. I don't think George Annas is anything like that. George's model isn't the charismatic, father-figure, leader type. He's a major voice, I don't have a sense of where the BU program is moving to. But I do have a sense of where the Georgetown and Hastings things are as much more culty-figure type leaders and it's not in a positive direction, I think. They have certain institutional things going for them. They have The Encyclopedia of Bioethics. They have The Bibliography of Bioethics. They have the two journals, particularly The Hastings Center Report. They have something at Hastings which I can't even believe they have, but they do. They have an endowment, which they never had when I was there. That will keep them chugging for some time. 643 SWAZEY: I have one more Center question. I wanted to ask you about where you'd put 644 Wisconsin? 645 CAPLAN: Well, Wisconsin I would put in a Virginia, I forgot about them but they're 646 important, they're an eighties important. They too are fading out right now. Oh, 647 you know who else I forgot, we should mention Pittsburgh just briefly. Wisconsin 648 is a program that is in jeopardy of not being there in five years. The way it looks 649 now, at one point they had some of the brightest stars going: Robertson, Fost, 650 Wikler, Alan Buchanan, Alan Weisbard, Alta Charro. But that is not a program

32 page FOX: 663 CAPLAN: that ever integrated into its medical school in any serious way. It was a free standing sort of Center. It was closer to the loose association model that Virginia had, is really the way I would describe it. It did not train many people. It had major voices and contributed vitally important scholarly things to bioethics, as individuals but not qua a systematically integrated program, is what I would say. Today, Norm Fost is looking to move on from there, for personal reasons. Lickland will leave the day his last kid gets out of high school because he wants to be near the opera and the theater. So he will be out of there. Alta is being recruited by every law school there is. This is a bright young law faculty type that people want to get at. Weisbard has actually been isolated at Wisconsin for two or three reasons because the religious stuff doesn't sit well there. I would imagine. He doesn't belong in Madison. He belongs in New York City. Correct, and that just doesn't sit well. Robertson's moved to Texas. Alan Buchanan was there in the philosophy department, now he's in Arizona. So my prediction for that program is that it was a loose association that's going to kind of Brownian-movement itself to a no-association. I don't think they're going to be there for very long. Pittsburgh, similar kind of phenomenon, important in the eighties. The program begins to gel. Meisel, Bob Arnold, Lidz, Roth, there's more, I'm forgetting some of them. On the physician's side, the anesthesiologist, critical care guy. Starzl's own bizarre influence, either generating ethics problems or... Frader is there. Schaffner is there from the philosophy end. Again, that's