DAVID NASH: Thank you Wendy. We've been spoken to a lot today haven't we?  This particular Harvard professor was a Nobel Laureate in the area of Physics and his area of specialty was thermodynamics. And because he was such a world, renowned professor, Harvard was eager for him to share his knowledge with other colleges and universities in New England. And he was asked frequently to come to colleges and universities and speak with students about his area of expertise in physics. Harvard being what Harvard is would always provide him with a chauffer to take him to his speaking engagements. And on this particular day he and his chauffer were headed for Vermont for a speech at one the small liberal arts colleges in Vermont. As it turned out this particular Harvard professor and his chauffer were always pretty much joined and they got to be good friends because of all the traveling they'd done together. It was the custom of the chauffer to always go in and listen to the Harvard professor give his lecture and as they were communicating with one another on the trip to Vermont the chauffer made an off handed comment.

He said, "Professor, I've heard you give this speech on thermodynamics so many times that I think I could give it myself." And the Harvard professor being somewhat of a practical joker said, "Well, hey, Gees pull over at the next rest area."  So they pulled over at the next rest area and the chauffer put on the university professor's suit and the university professor put on the chauffeur's uniform. And he said, "Let's try it and see how you do."  So they arrived at the college and the chauffer now alias university professor went to the podium and the chauffer sat in the back of the room to see how he was going to do. He was introduced with all the distinguished accolades that is associated with him and he got up and he delivered the speech. He gave the lecture on thermodynamics in an impeccable way, absolutely perfect. The university professor alias chauffer sitting in the back of the lecture hall was just absolutely taken aback with the way that this person had memorized all the intricacies of this speech that he gave on thermodynamics. After he had finished, the chauffer alias professor sat down and something unusual happened. The person who was moderating said, "Oh, professor, professor, we have about five minutes left over." 

This was not something that usually happened. He says, "We have time for a question or two."  And so the chauffer, being pretty good on his feet, stood back up and there were a bunch of people raising their hands. There's this one particularly aggressive young man down in front just dying to ask a question and so he called on him. And he stood up and he asked this long involved, technically sophisticated, difficult question about thermodynamics and about the lecture. You know, some students have a way of asking questions such as they want you to understand how sophisticated and knowledgeable they are whether they really want to know the answer to the question. He sat down. The professor looked him straight in the eye and he said, "Young man," he said, "I've given this lecture all over the world, many colleges and university campuses."  He says, "In all my years I have never had such a ridiculous, inane, and irrelevant question asked."  He says, "Just to demonstrate to you how stupid your question is, I'm going to let my chauffer in the back of the room answer it." Well, it's my understanding of after dinner, speeches is that there is no Q and A period. If somebody, if the moderator pulls fast one on me, I'm going to ask my chauffer, Wendy Mouradian, answer the questions.

The individuals who planned this particular conference can never be accused of not being expansive in their thinking. My assigned topic, Ethics, Leadership, and Public Health, covers a vast terrain of thoughts, terrain that is addressed in our universities not only in courses and curricula but in fact, by entire colleges. However, our planner's intentions are certainly noble, for a few concepts are as important today as these three. My challenge this evening is to, in some way, integrate them to you, for you, into some sort of meaningful home in order that we can identify the relevance of these three areas to our professional calling of promoting the health and welfare of the children of our country. This evening I'm going to examine the discipline of ethics and conclude that ethics is concerned with what constitutes the good society and the good life within that society. I will argue that the good society requires leadership, the extraordinary leadership of good people. I will suggest that health is foundational to the good life and that the colloquial expression expresses it well. If you have your health, you have everything. However, my focus in advancing the argument that health is basic will be on the health and welfare of children. If all children do not have an equal opportunity to succeed in life, they will be constrained in being able to realize their full potential because they do have inadequate health care.

Finally, I hope to accomplish my task in such a manner this evening, that you leave energized and recommitted to applying your leadership skills in such a way that you can make a significant contribution to facing the challenges, to dealing with the challenges we face as we try to insure that all of America's children have access to optimal health care. The French philosopher Voltaire once said, if you wish to converse with me, define your terms. As a result of my teaching of bioethics, I have learned that individuals have varying, sometimes conflicting and sometimes inaccurate understandings of the nature of ethics. Ethics is a discipline within the field of philosophy. It's a branch of philosophy that studies morality. In this sense ethics is the science of moral behavior. It is the intellectual reflection on and the study of the life of morality. Just the psychology is the study, the science of human behavior generally. If ethics is a domain of philosophy that studies morality, then we're forced to ask the question, but what in fact is morality?

A morality is that domain of understanding that relates us to our world and to other human beings within our world. Moral behaviors are those behaviors that can be evaluated as good and therefore right, using relatively objective, recent objective, impartial criteria. The concerns of ethics are the concerns associated with how we avoid causing harm to one another. How we prevent harm to one another. And in fact, how we also help one another. Ethics is about the social contract. It's about the implicit agreement about human cooperation that enables us to escape the state of nature with its many dangers and its many woes and to live with other human beings in a relatively safe, stable, and peaceful society, a society where all of us have the opportunity to experience the good life, a society that is characterized by fair treatment for all people.

There are two major dimensions of ethics although we generally tend to focus on one at the expense of the other. One is what we refer to as the ethics of obligation. How I ought to behave. How I should behave as I relate to other people. These universal rules specify what this social contract demands of us as human beings if we're going to cooperate with one another. The ethics of obligation focuses on more rules, rules that we must all abide by if we're going to insure that society in which we live is a society that enables all to pursue their vision of the good life. Examples of these rules of cooperation are: don't lie, don't steal, don't kill, don't break your promises, don't fail to do your duty, don't break the law, and so forth. All rules that we intuitively understand are the basis by which human beings learn to cooperate with one another. And we all acknowledge that they are very important to maintaining a civil society. Thus they can be summarized as don't cause harm or evil to other people. When we speak of ethics, these rules that oblige us not to cause harm to other people, generally come to mind. Therefore, ethics is viewed by most people as being concerned with controlling or restricting our behavior in specific ways. However, there is a second dimension of ethics, the ethics of aspiration. A dimension that is particularly relevant and significant to our discussion this evening as we consider this theme. To what should I aspire as an individual as I seek to live the good life?  What constitutes the good life for me?  How should I live my life such that at life's end, I can say I lived a good life? I lived a meaningful life, a fulfilling life, a purposeful life, a life with few regrets.

Parallel to and inseparable from consideration of the individual good life and ethics and the ethics of aspiration is also considering and discerning what constitutes the good life for society. That is, what is the good society?  In the fifth century before our current heir, a very wise Athenian by the name of Plato wrote one of the world's great tradicists using Socrates, his teacher, as the protagonist. His work was the Republic. In it Plato attempted to define the truly good society, a society in which perfect justice reigned. While on most accounts he failed in his effort, his attempt has inspired great thinkers up unto our current time to ask and attempt to answer the question of what is the truly just and good society. We can conclude from all of this that ethics is about behaving oneself, that is not harming others by obeying the so called moral rules. However, ethics is also about doing good things with our lives. Ethics is about exercising our unique talents in the pursuit of the good society. It is about aspiring to leadership in order that all human kind may share in what we understand to be the good life. What is the need now, was the query? Leadership was the reply. If led will the people follow, came the response?  If given the right kind of leadership, was the retort. Well, what is the right kind of leadership followed the question?  That which leads the people where they want to go echoed the frame. Where do they want to go?  Who knows? That's for the leader to figure out. Am I wrong to conclude then that what they want isn't leadership but rather follower ship. I suspect that some of us who have been seriously challenged in our attempt to lead, identify with this somewhat cynical assessment of leadership.

 Leadership is challenging. Leadership is difficult. Many individuals are skeptical about leaders and leadership. However, we affirm the necessity of leadership and everywhere we see people leading others. An always relevant and cogent question is to what end are leaders leading. The world has seen many strong leaders through its history, political, military, intellectual, in the lifetime of many of us here today, there have been leaders distinguished by their moral, we have seen leaders distinguished by their moral commitment. Mahatma Gandhi, Martin Luther King, Nelson Mandella immediately come to mind. However, also in our lifetime, we have seen leaders that we would characterize as evil. Hitler, Stalin, Pol Pot, were they not leaders as well?  Acknowledging that they too were leaders, forces us to affirm that when you are considering leaders and leadership, we must also examine the predicate of leadership. What is the end of one's leadership?  What or to where is the leader leading?  What is the aspiration of the leader?  What is the leader's vision?  Leaders become leaders because they have a vision. They've created a view of some future state that those who accept their leadership, view as a very desirable state. Therefore, these individuals come to share the vision. They become followers of the leader. A vision is a state that does not currently exist nor has ever existed, really. A vision is a target that beckons us. And it is perceived as the right target.

Ward Venice, the distinguished leadership academic, captures an important distinction when he says, "Leaders do the right thing, managers do things right."  The genius of leadership is the magical ability to clearly articulate a vision that is understandable, that's appropriate, that's meaningful, that's bold, and is energizing. Leaders are creative. Leaders think outside the box. Leaders challenge inherited assumptions. Leaders are people with ideas. A leaders' vision creates a focus for activity, an agenda to pursue, strategies to develop and implement. Martin Luther King's classic speech, "I Have a Dream" was a paradigmatic example of the characteristic of the vision of leaders. Leaders dream dreams. George Burns Shaw expressed it. Some men look at things that are and say why?  I dream things that never were and ask why not?  As a footnote to this idea of leaders being visionaries, I see suggest that leaders are learners. Leadership requires the bringing of considerable intellectual capital to the task of leadership. While education and experience provide this capital, my view is that capital is rapidly expended in a leadership role. And it must be continually renewed. My sense is that outstanding leaders are extraordinarily curios individuals with a keen sense, interest in learning.

Learning through their experience but also learning through the experience of others, and as a result of the need to learn through the experience of others, I also believe that learner, that leaders are readers. Knowledge is power. Knowledge empowers leaders and their vision. Leaders, in my view, become knowledge executives. Moral leaders create visions that are singular in their ultimate purpose. The improvement of the human condition, the searching for the common good, they have visions that move humanity closer to the good society, closer to the just society. A society in which all can succeed and in which all can prosper. A vision isn't necessary, but not sufficient condition for leadership. Leaders have to develop commitment from others to their vision. Therefore, an integral and critical component of leadership is influencing, educating, persuading others through communication guiding the development of opinions, helping others see the imperative of division being articulated to value the vision. In a sense leaders are the social architects of the group or the organization or the society for which they're providing leadership. They must design and build meaning for those who they would lead and continually communicate both the vision and a necessary commitment through their actions as leaders.

Visionary leadership always challenges the status quo. Visionary, there would be little need for leadership if the environment were never changing. We would need only managers not leaders. However, we live in a world of continuous change and such a world requires that the groups in which we live and work to change as well. But there's something in our human nature, that really resists change. We have an affinity for that which exists, I think, for stasis, and because we're comfortable with that which exist. We challenge change because it forces us to deal with the anxiety of the unknown. And as a consequence, gaining commitment to a vision requires a lot of courage on the part of the leader. Courage may be the leaders most important virtue, the courage to persist in transforming division into reality. Being courageous means taking risk, both personal and political, to stand on principle regardless of the consequences.

Distinguished German American theologian and philosopher Paul Tillich in his classic book, "The Courage To Be" said, courage is the strength of mind capable of conquering whatever threatens the attainment of the greatest good. Visionary leaders must continually challenge the status quo and the regnant power structure. They must have the courage to speak the truth to power. We have too little principle leadership today because we have too few courageous leaders. As social architects, leaders design and superintend changes in structures and processes to support the values and the behaviors that the new vision requires. Leading and making structural and processed change requires that leaders be people of character. Leaders must have the personal characteristics and quality that enable them to be trusted during this, as they are affecting these major changes. Trust is the emotional glue that holds leaders and followers together. And it enables followers to weather the winds of change that will buffet any entity that is in the process of pursuing a new vision. Virtues that characterize the personality of effective leaders we've heard about today. They're caring, sensitivity, honesty, fairness, empathy, curiosity, tenacity, consistency, energy, enthusiasm, commitment, optimism, and passion.

Passion is an interesting word and an interesting quality. Interestingly the meaning of the word passion in its root, is to suffer, to suffer, to be passionate about an issue is to be in suffering. In the context of leadership it can and must be said that leaders suffer to realize the vision. My expiration of ethics in leadership has been just a preamble to understanding the last of our three things and that's the health of the public. As professionals working in the field of public health, we have professed, that is we have vowed or we have promised for that's the very root, that's the root meaning of the word profession, to make a promise, to make a vow. We have vowed or promised that we will work to promote the health of the public. Such is our professional duty, thus such is our moral responsibility. So in an ironic and somewhat paradoxical twist, the ethics of obligation and the ethics of aspiration become conjoined for us, for our obligation is in fact, our aspiration. We aspire to fulfill our duty of providing leadership and promoting the health and welfare of children. In the context of our leadership duty, I want to suggest a vision for us. It's not a new vision. Rather, it's an old vision that has not been realized. It's a vision I trust will meet the criteria for the, the criteria appropriate for a vision that I outlined earlier. That it is a vision that is clear, it's understandable, it's appropriate, it's meaningful, it's bold, and it's energizing. And it's a vision that I trust will elicit passion with you, such an intense desire to see it realized that you will suffer under the imperative of division.

We must share this dream. It is the dream that every child in America no matter whether rich or poor, dark skinned or light skinned, bright or dull, Native American or Euro American, Latino or Asian, rural or urban, will have access to optimal health care, healthcare that is equivalent for all. Our dream is still only a vision for it envisions a future stage, one not yet realized in this, the richest nation in the world. Although we spend 14 percent of our gross domestic product on healthcare, we're only one of two industrialized nations of the world, the other being South Africa, that fails to provide its citizens with universal access to healthcare. As you are probably aware, the World Health Organization in the year 2000 ranked the United States 37^th in the world in healthcare. Despite significant expenditures of funds approaching two trillion dollars, over 15 percent of our population is without health insurance, that means approximately 44 million people and 25 percent of them, 11 million are children. Many with health insurance are only covered for a part of the year and maybe of those with health insurance have suboptimal coverage. U.S. infant mortality, a general indicator of general health status stands 42^nd in the world, with last year, seven deaths per 100,000 live births, primarily because of inadequate prenatal care. Children from our poor and near poor families here, they're the worst of these inequalities. These children suffer lack of well being and lost opportunity as a result of poor access to healthcare. American children from low income families get sicker more often and stay sicker longer than other children. They are two to three times more likely to have low birth rates, to be asthmatic, to develop bacterial meningitis, to lack immunizations and to suffer lead poisoning. Poor children are three to four times more likely to become more seriously ill and to have multiple illnesses. The health problems of our children are primarily from our failure to provide basic primary healthcare for them. In my field of pediatric rural health 80 percent of our tooth decay is found in the 20 to 25 percent of our children, approximately 20 million children that are primarily from African American, Hispanic, American Indian, Native Alaskan, and low income families.

Early childhood tooth decay, baby bottle tooth decay, if you will, is found in almost 70, between 70 and 90 percent of some very young children in some of our socio economically defined sub populations of the United States. The prevalence and severity of tooth decay is linked to socio economic status across all age groups. American children lose 52 million hours of school time each year due to dental care as your tooth decay. Toothaches are our children's, our teacher's most common health problem. Poor children experience all, nearly 12 times as many restricted activity days from their diseases do children from high income families. The so, called silent epidemic of tooth decay is no longer silent. It is screaming at us, do something. What does this say about a country in which every single American aged 65 years and older in the twilight of their lives and I'm approaching that myself, so I can say that, has access to healthcare through our nations Medicare program and our children, the most vulnerable of our population, lacks such universal access. The moral quality of any healthcare system is measured by how the vulnerable are treated.

Our current reality says much about the morality of America's healthcare system. Loretta Coppleman and Michael Polumbo have published a thoughtful and compelling and important article in the American Journal of Ethics, American Journal of Law and Medicine entitled "The U.S. Healthcare Delivery System Inefficient and Unfair to Children". The paper explores the four major ethical theories of distributive or social justice, utilitarianism, egalitarianism, libertarianism, and contractarianism. They conclude that no matter which ethical theoretical stance you take on issues of political justice, children should receive priority consideration in healthcare. Yet, our children do not even receive equal consideration, much less priority. Why? Well, one somewhat cynical answer might be that children do not vote. We are increasingly coming to understand that our nation may not be the nation with liberty and justice for all that we were taught in our high school civics class. But rather a nation who's understanding of justice is determined by special interests and by the money and power they bring to the campaigns of our legislatures and to the halls of Congress. While it would be informative and entertaining, I think, to explore each of these four ethical theories of distributive justice and why they support the imperative of children having priority access to healthcare. Our vision of universal access, I will limit myself to one theory, contractarianism, and (inaudible) it's the one with which I am most attracted.

One of the most important and influential books written in the 20^th century, a political philosophy, was written the late professor John Rawls of Harvard University and the book was entitled "The Theory of Justice". In it Professor Rawls carefully explicates the nature of justice. And his definition is based on what is now a now famous hypothetical, in which he asks people to stand behind a so called veil of ignorance and envision a world into which one is going to be born, however, not knowing the circumstances into which one is going to be born, that is to a rich family or to a poor family, intelligent or dull, male or female, European or African. He argues that given such a condition behind this veil of ignorance of thinking about the world you're going to be born in but not knowing the circumstance, that people will design a world that is fairly risk aversive. A world in which they will have equal opportunity to fulfill their potential, their unique potential, no matter what circumstance into which they're born. The design of such a world Rawls argued would make three conditions. Number one he said, each person will have an equal right to the most basic extensive liberties compatible with the system of equal liberties for other people. That makes sense. Two he said, persons with similar skills and abilities in this world will have equal access to the various positions in that society. That makes sense. And the third and critical one for our consideration of healthcare for children he said, social and economic institutions will be so arranged as to maximally benefit the worst off. Such a design, he says, would be just. Given a Rawls' end view of social justice, our nations healthcare system, if it is to be just, must be such as to be committed to nationally benefiting the worst off. As we have demonstrated, health problems are visited disproportionately on socio economic groups that are the least well off. Norman Daniels the Professor of Bioethics and Population and Health at the Harvard School of Public Health agrees with Rawls and argues that a just society should provide basic healthcare to all, but he goes on to say, but redistribute more favorably to children. He justifies this conclusion based on the effect healthcare has on equal opportunity for children, with equal opportunity being a very fundamental principle or basic principle of the requirement of justice.

As we've noted, our poor and minority children, the word most vulnerable in our nation and the worst off, have the highest prevalence of disease, the poorest access to healthcare and the poorest overall health. Justice demands that they be maximally benefited in order they have, ultimately have equal opportunity to do well. Equal opportunity is the clarion call of a system of justice in a nation of justice. However, there is a major disconnect today between what we say we value and how we allocate financial resources. The opportunity to realize one's potential in life is markedly effected by one's childhood. What happens in the life of a child is determinative whether that child will have fair opportunity to fulfill his or her unique potential, to be all he or she can be. I could not resist appealing to one additional theory of distributive justice to support this vision of universal access to healthcare for children. Utilitarianism is a theory of justice that emphasizes providing the greatest good to the greatest number. Utilitarian ethics tends to employ a cost benefit calculus. Utilitarians would argue for devoting resources to less expensive problems or prevention, rather than devoting resources to treating the more expensive health problems that may occur subsequent to their development. We all know prevention starts young. Prevention starts with children. As a German poet Gerte has reminded us, he who is wise begins with a child. Utilitarians, would want to obtain the most bang for their buck, if you will. They would argue that resources devoted to developing healthy children are wise investments because they are investments that will last for the lifetime of a child.

Contrast this resource sensitive utilitarian argument with the fact that we spend 30 percent of our total Medicare budget on six percent of the elderly during the last year of their life. Thirty percent of our healthcare budget in Medicare, on six percent of the people the last year they're are going to live on the face of the earth. If justice is to be served, if the good society is to be realized, the dramatic inequities that exist in health and healthcare for children must be addressed and addressed by us. Justice demands that our vision of universal access to healthcare can no longer be just a dream. The ethics of obligation prescribes our moral responsibility to cooperate with all human beings by obeying the moral rules, by not causing other people harm. The ethics of aspiration inspires us not only to develop a vision of the good life and the good society but also motivates us to provide leadership for that good life and that good society. Leadership requires that we articulate the vision, that we gain commitment to it, and that we be the virtuous people, that allows others to trust us in leading in the realization of that vision.

Our calling, the health of the public, specifically the health of our children forms our vision, a vision where all children can have equal opportunity for a good life because we will have provided them with the healthcare that they needed and they deserved. You are among our nation's leaders in advocating for and serving children. The fate of our children's future lies in the leadership in your hands. I challenge you to lead, to lead passionately, to lead well, to lead successfully and never stop leading until you are able to say that I have done all within my power and all within my ability to ensure justice for the children of our nation and our world. Thank you.