Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff. This episode is an audio version of a two-part video interview conducted by the Journal's editor in chief, Dr Audiey Kao, with American Academy of Arts and Sciences members Antonia Hernández, CEO of the California Community Foundation; Wallace Jefferson, former Chief Justice of the Supreme Court of Texas; and Eric Liu, the CEO of Citizen University. They joined us to discuss the American Academy of Arts and Science Commission on the practice of democratic citizenship, which is charged with developing recommendations aimed at restoring trust in our constitutional democracy. To watch the full video interviews, head to our site, JournalOfEthics.org, or visit our YouTube channel.
Dr Audiey Kao: Thank you all for being guests on Ethics Talk today. [music fades out]
Wallace Jefferson: Thank you. Good to be here.
Antonia Hernández: Pleasure.
Eric Liu: Good to be with you. Thanks for having us.
Kao: So, in November 1789, Benjamin Franklin wrote French scientist John-Baptiste Le Roy, concerned that he hadn't heard from his friend since the French Revolution began. After asking about Le Roy's health and events in Paris, Franklin talked about the U.S. Constitution's ratification a year before and the start of a new government under it. Quote, “Our new Constitution is now established. Everything seems to promise it will be durable. But in this world, nothing is certain except death and taxes,” Franklin said.
Compared to the pandemic response of many OECD countries, the U.S. government's response has fueled longstanding concerns about the vitality of our constitutional democracy. In light of the many societal fissures exposed by the COVID-19 pandemic, can you speak to the motivation and mission of the Commission on the Practice of Democratic Citizenship?
Liu: Well, Dr Kao, thank you so much for having us. It's really actually kind of a thrill to get to talk about this work with AMA members and the community of AMA members who care in particular about ethics. This is really a sweet spot for a conversation. I want to give a little bit of context. It's kind of apt that you quote Franklin in the early years of the nation because the American Academy itself was founded in 1780, even before it was certain that this would be a durable nation. But it was created out of essentially a leap of faith by John Adams and John Hancock and George Washington and people like Ben Franklin, who came together and said, you know what? We're not certain that we're going to win this Revolutionary War, but we are certain enough that if we do, we know that this new republic is going to need an institution that is meant to advance the “interest, honor, dignity and happiness of a free, independent, virtuous people.” and so, they planned ahead with that leap of faith.
And I think it's worth hearkening back to that, because we live in a time right now, as you allude to, where faith is hard to come by, when it comes to our democracy, where there is a lot of cynicism, and there's a lot of reason to be cynical. As you pointed out, our democracy's vulnerabilities right now have been utterly exposed by the COVID pandemic, whether it's the unresponsiveness of national government institutions, whether it's inability of Americans to sustain a sense of common good and self-sacrifice for a common good, whether it's the vulnerabilities of our voting systems when presented with a public health crisis of the scale that we're experiencing right now, the realities of our divided and disrupted media environment, and this continuous debate about what constitutes fact or science, and what authority factor science ought to have. All those things have been laid rather bare by COVID-19.
But I would hasten to add that all of those things long preceded this pandemic. All those things long preceded this crisis that we in. And indeed the work of our commission actually quite preceded the pandemic as well. We launched this commission over two years ago to investigate these very challenges about the weakening foundations of our democracy and the need right now to reinvent the way we think about and the way we practice as citizens in the United States.
And as we will talk about that more in the course of this conversation, we really came to see that there is a virtuous cycle, or if you neglect it, a vicious cycle, as among political institutions, civic culture, and civil society.
Liu: And when things are breaking as they sometimes seem to be right now, all three parts of that cycle are breaking. Political institutions are not responsive. The civic culture is one that yields to selfishness and short-term thinking. And civil society is divided and polarized in a way that is unable to sustain a sense of common good. But we came together as a commission across party lines, across region, across discipline and domain, because we actually have faith that it is possible to turn a vicious into a virtuous cycle by activating all three of those dimensions.
And I just want to say before I pass it on to Antonia, my colleague here, that my co-chairs in this commission, Danielle Allen of Harvard, who also leads an ethics-related entity, the Safra Center for Ethics at Harvard University, and Stephen Heintz, who's the President of Rockefeller Brothers Fund, were my co-chairs in this endeavor. And this commission included over 30 people from across the United States. And I'm just thrilled to be joined by two of them today who you've already introduced, Antonia Hernández and Wallace Jefferson. So, let me pass it over to Antonia.
Hernández: You raise the issue of the pandemic and the issues, and problems that we have been having as a country now, a democracy, have been longstanding. But when you combine and think about this, you combine a 100-year pandemic, you combine a 80-year recession, and we're just in the beginning, and then the social inequities, the killing of Black people and minority people. It's 50 years since the ‘60s that we've had this. The problems that this country has been having are longstanding. And I'm so happy that the Medical Association is really looking into this issue from a moral ethics perspective, because it's doctors who every day, nurses, medical professions who face this issue. You know, this report really raises the issue that we firmly believe that this is still a country of hope and opportunity. And as broken is our system is, it's still the best system around and that we can fix it. But we have to find that sense of communal, of belonging. You know, people are still at our borders dying, literally, to come into our country. We take it for granted. So, I think this conversation about the ethics and the role that each and every one of us plays in our society is critical to really re-energizing our democracy.
Hernández: And I turn it over to Judge Wallace.
Jefferson: Thank you so much for this wonderful opportunity to present some of our findings. You started out asking about the COVID-19 epidemic and the fissures that that has caused, but you also talked about 1789. And for me, this brings home a personal story. Because in 1789, as we all know, and even before the Constitution was in place, slavery was in place, which was, in my estimation, another pandemic that this country suffered from for a long, long time. And it seemed like there was going to be no way out of it, and it took a very impactful civil war and many years of additional trauma. But in my family's history, my great, great, great grandfather was a slave, and he was owned by a judge in Texas.
Jefferson: And some years later, not many years in world history, his descendant became Chief Justice of the Supreme Court of Texas. Oaky. So, if we could go through and get through that pandemic then, then with the help of medical professionals and science and with a hearty respect for the citizenship that our Constitution was meant to foster, we can overcome COVID-19. I think that is part of what democracy means: that we work together with the medical professionals, with police officers, with educators, with civic-engaging people, and come together and make our democracy as great as it needs to be.
Kao: Yeah, I think I appreciate that context. I'm sure our audience also appreciates some of that personal lens that you all brought to your commission's work. So, if I can move on. When practiced well, medicine applies the best available scientific evidence towards the care of patients in the right way at the right time. So, how did the commission go about gathering its evidence base, and how did that inform the commission's deliberations and the scope and nature of its recommendations?
Hernández: I think what's unique and important about this report is that the Academy convened 50 meetings throughout the country. They spoke to Samoan immigrants, they talked to refugees, they talked to people in Maine. I myself convened three convenings here in L.A. County, L.A. County, one of the most diverse places in the world. In fact, L.A. County is the world. It's a community of immigrants throughout the world. And we listened. And the interesting thing about listening, a good doctor, a good nurse, a good health practitioner, the skill that they really need is to listen, just to listen, and to try to understand where that patient is coming from, what's really the core of the problem. Well, that's what we did. We listened, and we heard. We heard about the pain. We heard about the inequities. We heard about the struggles that people have. But we also heard about this yearning: yearning to be in a place where they mattered, where they were counted in.
And one of the interesting things that we asked is, what unites us? Because we're not a country based on a particular color or look. America is the Constitution. It's an ideal: an ideal about living in a free country, exercising your right to your faith, whatever it is, to be, that government is accountable to you, that you are the government, and that there's this yearning. And we've sort of lost that sense of unity and belonging, and this is what the commission is doing: it's updating.
Kao: Yeah. No, I appreciate that. So, German physician Rudolf Virchow was an outspoken advocate for improving people's health by improving their economic and social conditions. He also entered politics serving in the German Reichstag from 1880 to 1893. Virchow said that, “Medicine is a social science, and politics is nothing more than medicine on a grand scale.” At a time when our politics are so polarized, what role do you see organizations like the American Medical Association having, if any, in revitalizing American democracy?
Liu: Well, I think that is a central question. And I think civil society organizations like the AMA are actually not incidental to, they are central to, they are paramount to the strengthening and reinventing of our democracy. I think you can look at this in one level, at a metaphorical level, of course, and the phrase and the language and the metaphor of the body politic is rather apt. The body politic in the United States right now is sick, and it is not a matter simply of one part of the body; it is a systemic, set of systemic illnesses, right? And that capacity to heal the body politic does not come just from a single external cure. This is about every cell in the body actually rejuvenating its capacity to carry lifegiving nutrients and lifegiving forces throughout the body. And I think civil society organizations, whether that's the smallest kinds of local neighborhood-based clubs, or whether it's a nationwide organization of professionals with great power and reach like the AMA, these kinds of organizations are fundamental, right?
Liu: And I think one of the things that you realize when you look at other societies that actually can adopt constitutions as well-framed and well-phrased as ours, what often makes the difference between whether that democracy sticks or not is whether there is a pre-existing culture of people showing up, participating, engaging in the life of the body politic through civil society, right?
And so, our theory of action in this commission, in this report, as I alluded to earlier, is that you have this cycle that's either going to be virtuous or going to be vicious, as among civil society, civic culture, and our institutions, right? And I think our opportunity right now, in speaking with you and all of the physician members of the AMA right now, is to really emphasize this ideal that I think was present during the founding of the country—people like Dr Benjamin Rush and others—the ideal of the physician citizen, right?
Liu: The citizen physician, in both directions. The doctor as a citizen and the citizen as doctor! Every citizen, whether or not you have an MD, realizing I am a part of healing the body politic, paying attention to what is off and what is broken.
And so, so much of our work in this commission, we came up with six broad strategies for reinvention of our democracy. Some of them have to do with institutional rule changes—and we'll talk about that—whether it's changing the tenure of Supreme Court justices or expanding the size of the House of Representatives. But others have to do with civil society, civic faith, and civic culture. Our six strategy is all about trying to create a shared commitment to American constitutional democracy and to each other.
Liu: As both Wallace and Antonia have said here today, this pandemic, like prior pandemics, whether you're talking about physical ailments or you're talking about deep societal evils like slavery, these pandemics reveal the depth or the shallowness of our commitment to each other, right? And so, civil society organizations like AMA cannot just be about advocating for doctors, cannot just be about advocating for the self-interest narrowly understood of the medical establishment.
Liu: Organizations like this have to be now, as a matter of ethics and civic morality, about how do we cultivate a sense of connection to everyone else? How do we actually recognize that physicians have this role of incredible trust and incredible power, and that it's a time right now to circulate that trust in that power on behalf of greater equity, on behalf of greater inclusion, and on behalf of ways that can actually build a sense of stronger bonds and stronger common purpose?
Liu: I run an organization called Citizen University, a non-profit, and all of our work is about trying to connect with practitioners like physicians all around the United States who are figuring out how to take the authority that they carry as doctors. People are going to turn to doctors for answers whether or not they have the answers! And that authority is not contained to just questions of medical science. That authority can be brought to bear on any number of things. And I'm not talking about policy positions. I'm talking about learning how to listen, learning how to engage with compassion, learning how to think more broadly about what constitutes self-interest, and recognizing that all self-interest is mutual interest in an interconnected, interdependent body politic, right? Doctors can lead that way by setting the example in changing our norms. And so, civil society organizations like the AMA have an incredibly important role to cultivate that sensibility within the medical profession.
Kao: Yeah. No, I appreciate your points. I think that looking beyond your narrow political interests and looking at the public interest is not something that the AMA has done perfectly, to say the least. But I think your point that it's a time where organizations like the AMA, other organizations that represent other professional and social collectives, whether they be doctors, nurses, lawyers, whoever, need to really stand up. Because, as you say, the body politic is in the ICU basically at this point.
Liu: If I could just add one thought here. I think one of the things that is striking about the world we live in right now and the complexity of our systems. You know in medicine, as do your members and colleagues, that a phrase has come into vogue in the last, I don't know, decade-plus of patient-centered care, right? And it's kind of telling in exactly the same way that in the education establishment, people are starting to talk about student-centered learning, right?
Liu: Is telling that a system gets so complex, so unwieldy, so kind of caught up in its own interests that it has to be reminded through a phrase like that, that the point of it was actually, in this case, the patient, or in the case of education, the student. And what we're talking about here is a citizen-centered democracy, right? Not citizen in the sense of passport holding documentation status, but citizen in the sense of member of the body, contributor to community. And our system and our democracy have focused too much on polarizing fights, on special interests, and not on the actual experience of citizens themselves in a way that Antonia was describing that gives them a sense of inclusion, possibility, and belonging.
Kao: Yeah. So, let's switch gears and talk specifically about the recommendations that flowed from the six strategies that you mentioned. And you already alluded to one of the recommendations being about the House of Representatives and enlarging the size of the House of Representatives. So, the last time the House was expanded to its current size of 435 was in 1913. Since then, the U.S. population has grown significantly. This has resulted in the average House district size increasing from 280,000 to nearly 770,000 people per district. And it's projected to reach nearly 875,000 in 2040. So, how do you think this recommendation and other related recommendations can contribute to our collective capacity to addressing long-standing social problems, including the health inequities that have been sadly, expectedly exposed by this pandemic?
Jefferson: Well, so, that is a great question. And the recommendation that you referenced is actually our very first in our report, and it's designed to strengthen our government to make it more responsive and effective. When the House of Representatives was created, it was meant to be the most purely democratic branch of the federal government. But as you have said, the House districts have grown so large that representatives cannot connect with their massive number of constituents in any real way.
Jefferson: So, we thought that expanding the House of Representatives would bring the makeup of this body in line with the founders' vision by making it more democratic and thus, more responsive to voters.
Voters should have a chance to meet and interact with their representatives and to take active parts in the democratic process. This is one of the things we learned from the surveys across the country, is that people really are hungering for some way to interact with their government, but they're seeing that interaction precluded in so many ways. And members of Congress who are public servants and most of whom care deeply about constituent services, will be better able to fulfill those services if they have a greater connection to the people.
There's another byproduct that can't be forgotten. If we expand the House, it would also make the Electoral College more representative of American voters.
Jefferson: The representative disparities that exist right now between small and large states are only going to widen in the decades to come. So, if we expand the House, and by extension the Electoral College, we can help to mitigate this imbalance.
And you mentioned that there are other aspects of the report that seek to do the same thing. I just want to mention one very briefly. And that is to help create a more representative and responsive government, our recommendation, 1.4 proposes independent redistricting commissions, which would remove the partisanship from the drawing of legislative districts. Recommendation 3.2 supports the creation of structured and engaging mechanisms so that every member of Congress directly and regularly interacts with their constituents.
Now, one thing that we've seen during this COVID pandemic, especially in my field, which is the legal profession, is instead of in-person meetings, we now have Zoom meetings just like this where we are able to talk to people all across the country and even all across the world. Now imagine if we put that technology in place and allow representatives in smaller districts to actually reach out and hear from and listen to the members, the citizens in their congressional districts. I think that spells good news out of a very, very tough and challenging pandemic for our future, and we need to grasp that technology and advance it to strengthen our democracy.
Kao: Yeah. So, if I could just follow up. You mentioned just now that increasing the House would make the Electoral College more representative. In recalling the commission's recommendations, I don't think disbanding the Electoral College was one of its recommendations. And I know that the commission thought very carefully about both the likelihood of its recommendations being adopted. So, recommendations that require constitutional amendments obviously create greater hurdles. Can you speak to some of those deliberations?
Liu: Sure. You actually allude to the very process that we had. As we said at the outset, this was a cross-ideological commission with members drawn from both major political parties and neither political party. And our aim was to achieve consensus on the body of recommendations. And so, I think one of the factors you named we certainly took into consideration. It is notable that among the 31 recommendations we make in this report that derive from the six strategies in there, only one of them actually would require a constitutional amendment. And that is the one that is about money in politics and Citizens United. But the deeper factor as well is that there are different points of view on the Electoral College. And it's not necessarily ideological, but it can be about smaller states versus larger states and rural areas versus urban areas. And though the idea of disbanding the Electoral College was certainly one that we discussed, it was not one that we were able to achieve consensus on.
And I think this approach that Wallace just described here of expanding the House, it's not only incidental that it has the effect of mitigating the distortions of the Electoral College. That was actually one of the key features of that proposal. So, on substance, I just want to say that. But on process, it's worth noting as well, because we've been citing Ben Franklin here a few times, that we really, as a commission, took pains to work in the spirit of Ben Franklin. And as you may know, at the end of the Constitutional Convention, Franklin rose, and it was still up in the air whether, in fact, there would get to be unanimity in that group there, in that room behind this fragile new document. And he gave a famous quote, which we actually put up on the screen at our final deliberation is a commission. And I won't read the whole thing, but the key sentence is, “Thus, I consent, Sir, to this Constitution because I expect no better and because I'm not sure that it is not the best. The opinions I have had of its errors I sacrifice to the public good. I have never whispered a syllable of them abroad,” right?
And the idea basically was, look, I'm not going to go out there and trash the parts of this constitution I don't like because everybody has a part of this constitution they may not love. But it is the whole that matters, and it is our ability to put out a whole from this diverse group that is going to send a signal to this fragile new nation. And we carried that spirit as much as we could in this commission and took that spirit seriously in recognizing that, sure, there are one or another recommendation that every commissioner may have qualms about. But we got behind this package with consensus in a way that was meant to model, in a sense, the possibility both of compromise and the necessity of having common purpose when you go out there to talk about common purpose.
Kao: Yeah, no. I appreciate your kind of giving us a window into the process and the importance of consensus building, reaching compromise to ultimately arrive at the common purpose recommendations that you all put forth.
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