by David J. Skorton, President
As prepared for presentation
May 29, 2008
Good afternoon and welcome. I offer my congratulations to the graduates of both schools here today. You are graduating from one of the most distinguished medical and graduate institutions in our country. I join with the faculty and staff, the Board of Overseers, the Board of Trustees, and your families and friends in congratulating you on the achievements, drive and dedication that led to this day.
As we celebrate with you, we also remember those who laid the foundation for your achievements. Among those whose contributions have helped bring us to this day was Cornell University’s good friend, benefactor, Cornell parent and member Class of 1957, Stephen H. Weiss, who passed away on April 16. Steve Weiss was the consummate Cornellian. He was the driving force behind the creation of the Weill Cornell Medical College Board of Overseers in 1980 and served with distinction as its first chair. He and his wife Suzanne endowed the deanship of the Weill Cornell Medical College, and he also served as chair of the Cornell University Board of Trustees. We all admired his ceaseless drive to make Cornell a better place, his vivacious spirit as well as his generosity that allows so many of us to strive to be our best. Please join me in a moment of silence in memory of our great friend Steve Weiss.
It is with great pride and admiration that I recognize the many clinical and research achievements of the graduates sitting in this hall today. We have students who have excelled in clinical care. Some have started to publish papers in first-rate medical and scientific journals, tackling problems in cardiovascular medicine, cancer, infectious diseases and other topics. They have ventured to distant, impoverished countries to assist local physicians in the treatment of underserved populations in places such as Haiti and Tanzania.
From the Weill Graduate School of Medical Sciences, we celebrate the graduation of 39 Ph.D. and 13 M.S. degree candidates, who already have to their credit more than 60 research papers published in journals of biomedical research and who have presented their work at national professional meetings as well as at the graduate school’s Vincent du Vigneaud Memorial Symposium. Fully half of the graduate students have also made time to serve as mentors for teachers and students in the New York City public schools.
From the Weill Cornell Medical College’s New York City campus, 45 women and 51 men are receiving M.D. degrees today. Twelve students participated in the Tri-Institutional M.D./Ph.D. program sponsored jointly by Weill Cornell, Rockefeller University and Memorial Sloan-Kettering Institute. More than half of the medical students have had medical educational experiences abroad, including 14 who worked at the Weill Bugando Medical Center in Tanzania. And many more have contributed their time and talents to community service projects —from drug and alcohol awareness programs in the public schools, to work with the homeless, to rebuilding the self-esteem of children recovering from burn injuries.
And, in what is truly a historic moment, we are also recognizing the first 15 graduates of the Weill Cornell Medical College in Qatar. Nine women and six men, they represent a variety of cultures and medical interests, and like their New York City colleagues, they have complemented their medical education with community service activities ranging from anti-smoking campaigns to vaccination drives. It was my great honor to be a part of the celebration of their achievements in ceremonies in Doha earlier this month, and I am most pleased to do so again today. Please join me in recognizing these pioneers, the first graduates of an American medical school offering its degree abroad.
The postgraduate opportunities won by our graduates are of very high quality and confirm the students’ high level of achievement at Weill Cornell. Even as we focus on the achievements of our graduates, though, our thoughts also turn to our neighbors in China and Myanmar who face unthinkable sorrow and the challenge of rebuilding homes, cities, and lives after the sudden and massive destruction they have suffered. These circumstances remind us of nature’s ability to radically alter lives with terrifying suddenness. Physicians and biomedical researchers should always remember and respect this, and with your strong commitment to service and your global perspective, intensified by your years at Weill Cornell, I am confident that you will.
One of the privileges of the medical and biomedical research professions is the right and responsibility for self-governance. The relationship between patient and physician and the relationship between researcher and the public both involve enormous trust that the actions of the physician and the scientist will always be based on achieving the best possible outcome for the patient and for the general public. Thus, the intentions and actions of the physician and the scientist must be motivated only by their aspiration to enhance the general welfare. For this reason, in addition to developing your skills as clinicians and biomedical researchers, your teachers have worked hard to impart to you a sense of the ethics that underlie medicine and biomedical research.
This afternoon, I want to highlight some of the new and challenging ethical responsibilities we face as doctors and biomedical scientists—something that must be part of your daily lives throughout your careers. First, let us remind ourselves of the differences between morality or general ethics and a professional code of ethics. Morality or general ethics are general standards of right and wrong. These standards are rooted in culture or religious tradition, such as the Ten Commandments or Shari ‘a law. Morality or general ethics can vary among groups in a society. In contrast, professional codes of ethics are attached to a particular group or profession and may need to be subjected to scrutiny in terms of general ethical standards. Professional ethics may conflict with the morals or general ethics of some segments of society, as in the case of embryonic stem cell research, investigations utilizing animal subjects, or the treatment of terminally ill patients. As advances in biomedical research and medical care occur, you must stay well-focused on the ethics of your profession, carefully considering each new ethical challenge in the context of the grounding in ethics that you received in medical and graduate school. At the same time, you will need to learn from your colleagues in the arts and humanities and to draw on the backgrounds in the arts and humanities that you gained in college and elsewhere.
In a 1959 lecture, C. P. Snow, who was both a scientist and a writer, raised the issue of the “two cultures.” Snow often spent his days working with scientists and then went off for an evening with his literary colleagues. “I felt I was moving among two groups — comparable in intelligence, identical in race, not grossly different social origin, earning about the same incomes, who had almost ceased to communicate at all, who in intellectual, moral and psychological climate had so little in common that one might have crossed an ocean.”
Medical ethics brings together the two cultures and, as physicians and scientists, you will need to live in both worlds. Medical and research ethics has been a part of your course of study at the Weill Cornell Medical College and Graduate School. Under the leadership of Dr. Joseph J. Fins, chief of the Division of Medical Ethics, and other faculty members in the division, the medical school strives to: “discover how to provide the most ethical care to patients and research subjects, to share this knowledge with current and future physicians and researchers through medical education, and to create standards of ethical care.”
M.D. students have taken a required six-week survey course in medical ethics. Topics covered in this course included: capacity, competence, informed consent and refusal; clinical pragmatism as a method of moral problem-solving for medicine; decisions at the end of life: issues in the hospital; ethics in reproductive medicine; the medical marketplace: access and managed care; and ethics in pediatrics. There is also a mandatory two-week clerkship to promote self-reflective practice and improve competencies in end-of-life care. The graduate students will also recall the Tri-Institutional course which imparted the principles of conducting ethically appropriate research and of dealing with issues related to conflicts of interest. At Weill Cornell Medical College in Qatar, students take a “foundations in ethics” course in their second premedical year. Also, for the past two years, student teams in Qatar have debated a controversial question before an audience of faculty, students, and staff.
Weill Cornell, like some 90 percent of medical colleges in the U.S., has also incorporated cultural competence training into the curriculum, in recognition that doctors and patients do not always have the same concept of health and disease. These differences in culture may be profound and fundamental and may, therefore, interact quite importantly in settings such as obtaining informed consent for medical treatment. Dr. Carla Boutin-Foster, associate professor of medicine, teaches cultural competence to first-year medical students in the Medicine, Patients and Society course. It is important that members of any profession not see themselves as “separate” or “above” the layperson, and teaching such as Dr. Boutin-Foster’s is designed to develop that appreciation.
These experiences, and the tools they have given you for dealing with complex ethical problems, will continue to serve you well. Advances in biomedical research and in clinical medicine will continue to pose dilemmas that cannot be answered by science alone.
In my own practice, caring for adolescents and adults with congenital heart disease, ethical issues surfaced in every clinic. Two types of issues frequently arose:
First, congenital heart disease can be an “invisible” ailment; that is, a potential employer or colleague would not know of the presence of a disorder without a report by the patient. How much information should the patient offer? Where does the personal orientation toward privacy and confidentiality intersect with the broader public good? The answer, of course, depends on the situation, the nature of the potential employment. For example, I saw patients who sought employment as drivers of cars, trucks or buses—a situation where their cardiac problems could have consequences for others. If the patient had an obvious risk factor, such as a history of faintness or severe abnormalities of the heart rhythm, of course I would interpose myself in the employment process. But what of the more usual and more subtle situation in which there was no definite high risk factor to preclude driving? In these latter circumstances, I urged my patients to disclose as much as they felt comfortable disclosing, erring on the side of more full disclosure. We then depended on the Americans with Disabilities Act and other approaches to prevent discrimination in hiring.
Second, we faced the familiar dilemma of the physician who cares for adolescents: when is the history to be taken with or without parental involvement? I left it up to the patient, except in cases where, in my judgment, the patient would be at significant risk—a risk that the parent should be aware of. How many times we faced the dilemma and frustration of the high school student-athlete found to have congenital heart disease, who might have to sit out the season—or give up the dream of competitive athletics completely—rather than risk life-threatening complications during exercise. In those frequent gray zone cases, where there was no definite contraindication to exertion but we could not guarantee a safe outcome, I depended upon the good communication and partnership formed with the patient and the parents to arrive together at a decision.
I cite these examples not to ask your endorsement or adoption of my solutions, but instead to illustrate one physician’s interactions with ethical issues in day-to-day practice. As new graduates you will face these sorts of issues and many new ones. For example, take the rapidly developing field of personalized medicine, where great advances have been made in identifying genetic markers that might signify increased risk for specific diseases or might guide therapy. This emerging field offers great promise, but is still in a stage of development and validation. As the field of personalized medicine progresses, it behooves all of us to ensure the accurate communication of scientific knowledge and research outcomes in order to leave the public with a realistic assessment of the likelihood of benefit to the individual patient from research findings and new approaches to patient care.
The use of genetic testing brings with it many additional ethical dilemmas. Francis Collins, director of the National Human Genome Research Institute, told Congress last year that about a third of people with family histories of a disease decline to participate in studies to find new genes that carry disease risk because of fears about the misuse of that information. For example, could having a genetic risk factor for a certain deadly but untreatable disease result in refusal to treat someone aggressively for another, treatable disease, on the grounds that the person is likely to succumb to the genetic disease anyway?
Fortunately, Congress recently passed and President Bush signed the Genetic Information Nondiscrimination Act to prohibit discrimination by employers and health insurers on the basis of genetic tests, and it became law on May 21. The bill, first introduced in 1995, is seen as removing a major obstacle to personalized medicine, that is, the utilization of genetic information to choose the best treatment for each patient.
The Human Genome Project website lists many other societal concerns arising from the “new genetics.” These concerns range from psychological issues and stigmatization, to reproductive matters, to the ethics of testing for a disease when there is no effective treatment and the disease has not yet expressed itself in the patient. This abbreviated list of questions is humbling, and many do not yet have easy answers. How do we respond to questions such as these? As physicians and scientists, perhaps we need to recognize more fully the need to understand and appreciate values, and the modes of knowledge that let us understand values. I urge you to pay particular attention to the evolution of ethical constructs and their application to your practice or your laboratory.
Your years at this medical school have provided you with the finest scientific and clinical training available. I hope they have also given you a strong ethical and moral framework that will continue to provide context and meaning to what you do—long after some of the specific techniques you learned seem quaint and obsolete.
As president and as a fellow physician I charge you, the graduates, to:
- use your broad and deep wells of knowledge and abundant clinical skills to prevent, diagnose, treat and often cure disease, but always to comfort, to empathize, to work as a true advocate for and partner with your patient;
- keep the lessons of biomedical ethics foremost in your mind as you deal with ever-changing and ever more complex methods and capabilities in modern medicine;
- for those of you pursuing research, to remember that the purpose of your investigations is to uncover the truth, no matter whether positive results or negative, no matter whether the hypothesis you favor is accepted or rejected;
- and remember the very thin separation between the powerful and the powerless and maintain the humility and humanity that makes for the best medicine.
On behalf of Cornell University and the faculty and staff members who have been partners in your efforts over these past few years, congratulations on your achievements. We are enormously proud of what you’ve accomplished, and we wish you continuing success as you move through your careers.