“Morality Without Apology: Reclaiming Hubert Humphrey’s America”
Diana Chapman Walsh
University of Minnesota
September 9, 2012
The invitation to present this lecture was irresistible on several counts. First, the purpose of the series has great salience in the present moment — to consider the kind of leadership we need, across society generally and, in particular, at this time of great uncertainty, throughout the health care system. Second, one couldn’t help but be impressed by the lineage of the lectureship — the very distinguished roster of previous speakers. It’s an honor to join their company. Third, the linkage of the lecture series to the “emerging physician leaders” program roots the occasion in the aspirations of real leaders taking on real problems. Fourth, the warmth of the invitation was another distinct draw — from Dr. Rothenberger the inspiration for the lecture series and his colleagues. And the ultimate magnet — as is so often true — was the pull of friendship. In my case the Goldberg family, and especially my dear friend, Luella Gross Goldberg.
The invitation presented challenges as well. My area of deep expertise and personal experience — the ground on which I have stood (and from which I have led) for the past 20 years — has been higher education far more than health care. I was a scholar of health care policy in my early career, and — now — in a distinctly different role, have after a long hiatus returned to that field as a member of national governing and advisory boards (as you’ve heard). But bringing the two worlds together in a way that might have currency for you required some mental gyrations on my part through the summer. Luckily I found them enjoyable. Now we can all hope that you will too.
I begin by taking my inspiration for the title of this talk from my colleague and friend, Donald Berwick. It was he who recruited me, five years ago, to the governing board of the Institute for Healthcare Improvement (IHI), the organization he co-founded and led for over 20 years. As you may know, Don returned to Boston in early December after 16 months of service running the Centers for Medicare and Medicaid Services, CMS.
He held a recess appointment that was never renewed because it became a lightning rod in the fight over the act of congress that, despite its complexity and flaws, finally “erases the major injustices that [have] disgraced American medicine” and satisfies “a fundamental requirement of political decency that every other mature democracy .. met long ago.” That’s a quote, an assessment of the Affordable Care Act by legal scholar, Ronald Dworkin. Don Berwick calls it, simply, “a majestic law.”
Always a riveting orator, Don brought back from the nation’s capital a voice that is carrying greater urgency and moral heft since he left. It is the voice, as he has said, of morality … without apology. My basic thesis today is that more of us need to be finding our own words — and ways — to carry our versions of Don’s message …that more of us — indeed all of us, no matter what roles we are playing in organizations, places of work, communities and the civic sphere — need to be thinking of ourselves as leaders, and as leaders of a particular sort, conscious of opportunities to speak up for those things we most value in the worlds we inhabit, committed to creating venues in which others can find and speak their truths, can seek deeper understanding and forge coalitions to work for the common good.
I want to ask whether we can be less coy about engaging those around us in thinking — with us — about who we are and want to be as Americans, about what we believe makes our lives worth living, what we can do to secure a future worth having, for ourselves, our kids, our grandkids … my three-year old grandson, Sean.
For I worry — with many others — that the foundations of our democracy are being eroded by our growing unwillingness to examine “in the public square” the moral and spiritual convictions that are being twisted in the endless spin machines and then lost in choices being made by default, without the care they warrant.
And that takes us back to Don.Just days after he left Washington, last December, Don galvanized an audience of several thousand health care providers at IHI’s annual forum. He titled that talk “The Moral Test,” and it’s available on-line.The following May, he addressed Harvard’s physicians and dentists as they received their degrees in a talk entitled “To Isaiah,” which appeared in JAMA on June 27. You may have read it.
What caught my eye for this encounter with you was that on both occasions Don quoted the late Hubert Humphrey — the legendary public servant of your city, your state, your university, our nation — in words inscribed in the entrance to the headquarters of the Department of Health and Human Services that bears the Senator’s name.
“The moral test of government,” Humphrey said on the occasion of the building’s dedication, “is how it treats people in the dawn of life (the children), in the twilight of life (the aged), and in the shadows of life (the sick, the needy, and the handicapped.)”
Don’s Washington experience has forged him into an even stronger prophet than he has long been on behalf of quality health care, leading IHI in its pursuit of a “never-ending campaign to improve health and health care worldwide, to improve the lives of patients, the health of communities, and the joy of the health care workforce, and reduce health care costs.” That’s an ambitious mission, being stewarded, ably, since Don’s departure, by Maureen Bisignano, his long-time co-leader and, now, successor.
In his new role, Don is asking all of us — “We the People” — to find the moral courage, the wisdom and the compassion to face up to Hubert Humphrey’s test — a moral test, he says, not only of our government, but also of our society, our country, and of your professions — many of you — the healing professions and those that surround and support them.
For if you cure the patient’s leukemia, as Don did Isaiah’s, only to watch him die violently of a disease Don named “hopelessness,” have you met your obligations as healers? Have we passed the most basic test of what it should mean to be a United States citizen? Dr. Berwick warned the Harvard graduates that the answer is no:
“Isaiah’s life and death testify to a further duty, one more subtle—but no less important … It is to cure, not only the killer leukemia; it is to cure the killer injustice.”
We’ve learned a lot about leukemia — not enough to be sure, but enough to accord it a hopeful place in the chronicle of modern medicine’s epic struggle against “the emperor of all maladies.” At the Broad Institute Eric Lander occasionally reviews with the board an elaborate “cancer map” illustrating both how far we have come in the decade since sequencing the human genome and how far we still have to travel. We’ve learned what we need to do, Eric says; what remains is to get on with it.
What have we learned about injustice?
One thing we do know is that injustice breeds inequality (and vice versa) and that inequality is an independent cause of illness and death, other things being equal. Across time and space, and along the life span, a person’s position in a socioeconomic hierarchy affects her health and longevity. In Aaron Antonovsky’s unforgettable words — and his metaphor from the Titanic — “Death is the final lot of all living beings but the age at which one dies is related to one’s class.”
We have a substantial literature on health inequalities, on poverty and health, and on connections between extreme poverty in the US (Michael Harrington’s “Other America”) and disease burdens we associate with developing countries. A growing number of American households live on less than two dollars per person per day, more than double the number 15 years ago, 1.46 million now.
We know that poverty kills, directly and indirectly, with the hopelessness that killed Isaiah. Less obvious, perhaps, is the finding that inequality itself — the gap between the top and the bottom in a society — affects its population’s health. That’s the social class gradient in health that Alan Marmot and his colleagues highlighted in the late 1970s among British civil servants, the stepwise gradient that pointed to the effects of something more than just poverty. Each group on the socioeconomic scale had higher mortality rates than the one just above it. The pattern applied across many of the major causes of disease and showed up in morbidity data too.
Other research showed that the countries with the most equitable distributions of income or wealth had the healthiest populations, and the countries that improved equity over time showed the greatest improvements in the health of their populations. These findings were gaining currency at around the time, 1990, that I was being recruited to the Harvard School of Public Health by Harvey Fineberg — dean then — to re-found and lead a modern department of “health and behavior.”
Harvey had majored in psychology at Harvard; my graduate training was in medical sociology. We arm wrestled briefly about the department’s mission as expressed in its provisional title. Ultimately, we settled on a compromise that threaded a path between the intellectual claims of larger departments. You can imagine that dance. We wedged the word “social” into Harvey’s original proposal and I agreed to chair a new department of health and social behavior. We didn’t say much about what we meant by “social” behavior but I needed that word because the one thing of which I was certain was that health was a social phenomenon as surely as it was a biological one.
We launched a program called Society and Health and set out to codify and trace some of the major social factors affecting the health of populations. But the Wellesley presidential search committee (Luella playing a prominent role) plucked me out of that position before we ventured very far.
I relate that bit of personal history in part because it accounts for my selection of inequality as the theme for this talk. It explains, as well, why I was excited, while preparing for this encounter with you, to immerse myself in a summer reading program that puts Don Berwick’s Isaiah challenge in a broader context, while underscoring its importance, urgency, even portent.
Let’s take a quick look at a representative few of those writings on my reading list. And then we’ll strike out on our own.
Joe Stiglitz, a colleague from the Amherst board and the 2001 Nobel laureate in economics, has been writing more for lay audiences since winning the prize. His most recent book, The Price of Inequality, addresses Don Berwick’s charge to the Harvard graduates, Don’s charge to us, through the moral vision of Hubert Humphrey.
Joe documents an enormous increase over the past quarter century in inequalities of wealth and income in the US. He summarizes and contextualizes extensive cross-sectional and longitudinal data and explains in detail why and how the gap has widened so fast. And he spells out why we should care.
We are making collective decisions, his book shows, that have rendered the US economic system not only “inefficient and unstable” (bad enough), but also “fundamentally unfair” and “we are paying a high price for our inequality,” which — Stiglitz argues (quoting him) — is distorting “our political system” and threatening to erode “confidence in our democracy and in our market economy … along with our global influence” and even, if trends continue, “our sense of national identity.”
All of this reflects choices, Stiglitz adds, not inexorable natural processes, a cause for both hope and despair. We know how to create “a more efficient and egalitarian society,” we have time-tested policy tools. That’s the hope.
The despair is that “the political processes that shape these policies are so hard to change,” the more so as the “moneyed interests” have re-written the economic and political rules of the game, while masking their motives and deflecting public awareness from the extent of inequality, the reasons for it, the injustices behind it, and the corrosive consequences flowing from it. That’s Joe, trying to redress the balance.
He is joined by Paul Krugman, in his new book, End This Depression Now. Krugman shares Stiglitz’s frustration. He too sees the political gridlock in Washington as a symptom, in large part, of concentrated wealth. He writes of “a small but influential minority,” insulated by “extraordinary income growth,” that has “chosen to forget the lessons of history and the conclusions of several generations .. of economic analysis, replacing that hard-won knowledge with ideologically and politically convenient prejudices.”
The longer-term lessons of history are the focus of a fascinating analysis of Why Nations Fail (the title of their recent book), by a pair of senior economists, Daron Acemoglu at MIT and James Robinson at Harvard. Strong economic and political institutions are the sine qua non for success, they show, not geography, or natural resources, or culture per se. Through two thousand years of history, nations that fostered economic growth and prosperity for their people did so because of manmade institutions that avoided decay and stagnation through political systems that resisted capture by elites.
So, are we being captured by elites? Yes, warn a number of other economists, social scientists, and public intellectuals, who often work at the margins of their disciplines in and out of the academy. Some are advancing a vision of a “new economy” as an alternative to what Juliet Schor labels “business-as-usual” (BAU) markets. BAU markets, they say, assume and create a scarcity mentality and ever-escalating consumption that despoils the environment and diminishes the quality of time-starved and stress-filled lives.
These critics call for broader measures of prosperity and for policies supporting wiser choices at the individual level that they hope can — over time — yield benefits on the ecological and human levels. In Schor’s words we can choose to “work and spend less, create and connect more .. emit and despoil less, enjoy and thrive more.” This sounds appealing … and wildly unrealistic, romantic, even naive. Why? Because that’s not who we are any more.
A new book by the influential Harvard ethicist and legal scholar,Michael Sandel (known for his PBS course on justice), explains why. Sandel’s What Money Can’t Buy, tracks the expansion of market reasoning into all aspects of modern life — “the commodification of everything,” he calls the trend, which he documents arrestingly in a litany of examples that are so ubiquitous and familiar that we’ve mostly stopped noticing them pile up. You can upgrade your prison cell for $8/night; hire a surrogate mother from India for $6,250; buy the cell phone number of your physician for $1,500; emit a ton of carbon into the atmosphere for $18; and — an example he cites from Minneapolis — drive solo in the carpool lane at rush hour for $8, although my driver yesterday said it varies by the level of demand and can cost much more than that on busy holidays.
Expansion of the logic of buying and selling, Sandel says, “has sharpened the sting of inequality by making money matter more throughout the whole of life. At the same time it has divided us — he coins the phrase “skyboxification” — with “people of affluence” sitting high in glass-encased skyboxes (real and metaphorical) oblivious to the concerns of the people below.
Everyone’s experience is impoverished as a result, he says, not only because the incursion of market logic where it doesn’t belong degrades the value of things “that money can’t buy,” but importantly because it undermines democracy. A thriving democracy requires, Sandel concludes: that “people of different backgrounds and social positions encounter one another, and bump up against one another, in the course of everyday life. For this is how we learn to negotiate and abide our differences, and how we come to care for the common good.”
Well, there was more on the reading list, but I will take mercy on you now and ask: if these analyses, and others like them, are mostly on target, if they offer the analogue of Eric Lander’s cancer map — what does this moment require of us? Our understanding surely, our best attempt to reach our own conclusions, with the most reliable information we can assemble, our own and ongoing year-round reading lists.
I’ll put in a plug for another of my boards, The Kaiser Family Foundation, which has carved out a role as a trustworthy source of nonpartisan analysis to inform health policy, with special emphasis on the impact of policy on people. There’s a wealth of information on their websites. We can be better informed. But is there more that these times demand of us?
One thing more, I believe.
We need to evolve a different discourse about difference in this second decade of a new millennium that is teaching us, if nothing else, how radically interdependent we are as an immature species on a fragile planet.
We need a new understanding of how to transform our conflicts rather than glossing them over as too hot to handle while we draw farther apart. We need a commitment and a set of skills to engage at a deeper level through conversations that open us up rather than shutting us down.
These sound like homilies but what I have to offer are concrete experiences from leading Wellesley, hoping they may have some resonance for you. Colleges and universities are in many ways petri dishes for working through problems confronting the larger society.
During my time at Wellesley — as on other campuses — we were watching the twin forces of globalization and technology tie humanity, at breakneck speed, into more and more complex networks of mutual dependency.
And our own local struggles were reminding us of the work we still have to do if we are to evolve the social sophistication required to live interdependently — in our diversity — now living side-by-side with otherness to a degree never before seen or imagined. Peter Senge calls this “the greatest learning challenge human beings have ever faced.”
Little wonder, then, that the challenges that brought me to my knees as a college president originated, more often than not, as disagreements over differences. The pattern was established in the first months of my presidency, with a big test in a very public battle between two senior professors — a Jewish woman, a classicist, and a black man, an Afrocentrist, who become caricatures of themselves as they took one another on in escalating cycles of contempt and calumny. That struggle occasioned a one sentence note from the president of a Quaker college — a school rooted in pacifism. ““Welcome to the culture wars,” it said.
Though never again on that scale, the tests continued through my 14 years on the job, in the typical parade of campus skirmishes: student-led uprisings over identity and power, conflicts within academic departments playing out ancient grudges or reacting to shifting alliances, eruptions on the electronic conferences, sticky judicial cases, unpopular tenure decisions, controversial hires, provocative speakers, and many not-so-subtle bids for institutional resources and recognition, inflected, more often than not, with identity claims.
At the same time – and this is important — I loved being president of Wellesley; it was the privilege of a lifetime in every respect, and, in most respects, it was a joy. And this tough and confusing arena — this engaging of our differences — was, oddly enough, among the richest and most fertile fields we had for deep and sustained learning — mine, that of my administrative team, the faculty, alumnae, trustees, and, especially, the students.
I can’t count the number of times a student would circle back to me with a new take on a particularly painful eruption. There might have been tears in my office, protests in the halls outside, angry email exchanges, temper tantrums … the whole mishegas.
But then, later, one or another participant would re-emerge, through a note or an email message, at a five-year reunion, occasionally in more public way — in a speech or a writing. She would find a way to let me know how much the incident had taught her, how grateful she was for the lesson, hard-won though it was.
So the students taught me early that the way to survive the culture wars would be to convert them into learning experiences, to push them deeper than they might otherwise have taken us without a nudge from the president — a nudge intending to open a new opportunity for institutional growth.
And the trick, I learned, was to view differences as inevitable and healthy — not something to be managed or suppressed — to hold, honor, and amplify the differences within the community as a necessary step toward forging bonds of unity.
This meant admitting that no college — indeed no institution — will ever be a utopia, free of ignorance, incivility, and disagreement. When we tried to smooth all the rough edges we would find that we had muted or marginalized dissent and driven it underground.
We came to see conflict as a necessary, generative force and differences of opinion and experience — polar positions and contradictions — as a critical part of any learning process. Learning involves first mastering new categories and then integrating them into a larger, more organic whole.
The differentiation stage requires heightening and sharpening differences — intellectually and experientially — widening the gap between two opposing poles, really seeing and feeling what’s different — walking all the way into a charged or hostile field. Absorbing its energy.
The integration stage becomes possible when, finally, you are able to find a new position — a new place to stand — that incorporates the two conflicting realities in a third, more complex and more comprehensive whole. That’s the essence of the creative process.
But while we needed our differences heightened and amplified, not muted and papered over, we also discovered how important it was to avoid over-personalizing those differences, converting them from divergences of viewpoint, fact or interpretation, to personal attacks, affronts and wounds — or triggers to that most corrosive of emotions, humiliation.
When conflict becomes personal, it deepens resentment or threatens a relationship and shifts the focus from the intellectual work of understanding and learning about a substantive difference to the emotional work of mending or compensating for a damaged relationship, or of hunkering down in anticipation of retaliation.
When we were able to discover and address the true and legitimate needs expressed by voices at the margins (needs that are seldom reflected accurately in the symbolic or emotional demands that surface at first), then we saw ways to improve the situation for everyone. So the task was to design encounters where we could penetrate through the presenting symptoms to something more fundamental.
These kinds of deep encounters required a willingness to be changed, to engage others fully, expecting to absorb aspects of their otherness — openly, respectfully, empathetically — being prepared to let the other’s testimony shake your unexamined assumptions.
And so the demands of leading in this way required inner work as a necessary complement to the management of external events. I came to understand the inner work of leadership as indispensable, the work of paying close attention to how I was leading myself.
Accepting the presidency had been a fairly blind leap for me and I faced a steep learning curve when I first took up the job. The initial years were daunting, to say the least, as I fashioned myself into an entirely different person than I’d ever been and learned about a whole range of practical issues I’d never thought about.
But by far the most disconcerting adjustment was an emotional one, as I learned to stand in a force field of projections coming from every direction. People were constantly sending me signals about what I would have to do to win their approval. They would love me one minute, then hate me the next, all the while imagining me as the leader they unconsciously needed me to be — sometimes hero, sometimes goat.
It took discipline and conscious effort to learn to guard my spirit against the dehumanizing effects of this echo chamber of projections, to find solid ground on which I could stand apart from the expectations of others without losing my connections to them.
Too often, instead, leaders fall into one of two traps. They let their egos get hooked and soon they’re sucking all the air from the room. Or they are crushed by the criticism and build walls around themselves.
I knew I didn’t want to lead in either of those lonely ways and so, with help, I worked hard to evolve a distinctive style of self-conscious leadership rooted in a network of resilient partnerships and anchored in the belief that trustworthy leadership starts from within.
It was a long story and I’ll compress it by saying simply that first of all, I was lucky to assemble an amazing team of colleagues — trustees, faculty, vice presidents and deans and other staff.
And then we learned together. I learned; my partners learned; the college learned. And the learning is the point. With time, intention, concentration — when we allow our minds to drop down into our hearts — we do learn to change ourselves. And when we change ourselves, things begin to shift.
Our learning at Wellesley began in self questioning, and in an appreciation of the “relational, ecological, and interdependent” nature of the world. We learned to take seriously the assertion that knowledge is provisional and that knowing a communal reality requires engaging it directly and seeing it whole, or trying to.
We drew on systems theory and complexity science, looking for connections, and for the deeper structures that repeatedly produce results no one wants. And from that followed the imperative of listening to many voices, assembling different perspectives, fostering collaborative efforts to build more compelling narratives — both of our current reality, and of a preferable future many could want.
We learned to reflect regularly on our own motivations and self-delusions, while at the same time working with others to read the force fields in the larger system. This enabled us, over time, to break down boundaries, forge new relationships of mutuality and trust, unleash the generative power of multiple mental models, and create new realities.
What we learned about how to work with difference was contrary to conventional notions about how to drive deep systemic change within an organization. The commonplace idea is that the change process requires altering structures, issuing directives, developing strategic plans and systems of accountability — that real change, transformational change, is BIG, top-down change.
These steps are important, of course, but in our experience the hardest work of transformational change was the quietest part, the inner and interpersonal dialogues through which we gradually reconsidered habitual ways of thinking.
We saw the inside shift precede the outside one, or dance with it over time as individuals and small groups began to shift their mental models about how the world works and their taken-for-granted assumptions about the rules of the game.
This is akin to the slow transformation through which Americans have been moving for the past century in our understanding of race, and, much more recently, sexual orientation.
Ironically, though, as we’ve just seen, a similar transformation has heightened our tolerance of inequality. Shifting that perception is going to take time, patience, humility, and Martin Luther King’s faith that the arc of the universe bends toward justice. Inequality is bending the curve in the opposite direction.
And, so, I would like to leave you with the thought that — as you continue to pursue with scientific rigor and with passion the challenges of advancing medical science, delivering the best possible medical care, and, at the same time, reforming the health care system so that it works better for everyone — you also hold space in your minds for the larger context signified by this Rothenberger lecture series.
For our culture urgently needs — in all sectors, including your own — next-generation leaders who will be equal to today’s challenges in all their complexity and who will be skillful at leading themselveswith compassion and equanimity … with love — love understood as connection in the way Paul Tillich defined it: the unifying impulse, the recognition of our interweaving with all living beings.
What if the way ahead for a safer, saner future is a leadership grounded in connection, in love? Can we sculpt leaders who are gifted in the ways of community and connection? Can we grow up leaders who “lead from within,” as Parker Palmer has advocated, who understand that they have a special responsibility to manage their own inner shadows, lest they cast more shadow than light on those around them?
Ah, the rejoinder comes, these are times for muscular leadership. We are told to be afraid, be very afraid, and to place our trust in heroic deciders offering simple comforts. But surely these nervous times call for Einstein’s new levels of thinking, the more urgently if we believe we’re entering a period of profound change. What kinds of people do we want leading our vital institutions through historic transformations? How do we want them to lead? What should we expect of leaders we can trust?
I’m convinced we’ll need leaders who can bridge and balance tensions without collapsing them, who can hold contradictions creatively so that they will open our minds and hearts to wider syntheses, rather than shutting us down.
We’ll need leaders who can hold the contradictions between power and love. “Power without love is reckless and abusive,” Martin Luther King said in the last weeks of his life, “and love without power is sentimental and anemic. … [The] collision of immoral power with powerless morality … constitutes the major crisis of our time.”
At Wellesley, I learned that my power—the power of the presidency—existed for the essential purpose of enabling others to find their purpose, their authority, their self-authorship. And I learned that to achieve this I would have to remain open to others in a way that is the essence of love as the drive to sustain unity and maintain connection.
I would have to respect the other person’s reality, the other person’s yearning, the other person’s path of growth, to be open to influence back from others and their different realities. And this in turn taught me the value of diversity as a resource for learning in a community.
I learned to hold another tension — and this one was harder still — to honor my inner life in the face of all that was swirling around me. It took time and concerted effort to develop the skills to manage external realities and yet maintain a quality of attention in the present that could enfold past and future, embrace complexity, and help me try to meet each new moment with equanimity.
I didn’t always succeed at this — far from it — but I learned to find my way back when I was lost, and to know this quality of mindful presence as a capacity I wanted for myself, and for my leadership team, because I wanted it for our students.
It’s been said that this new generation, escaping into social media as their world spins out of control, is being raised on “information without context, butter without bread, craving without longing.”
And yet, we have good evidence that today’s youth are longing for more nourishing fare. The disciplines they will need in the years ahead are the ones we will all need and they are a life’s work, never fully mastered, always requiring conscious cultivation.
We’ll need the strength to stare down our demons of fear and despair so that we can engage the world with curiosity, opening our minds and freeing ourselves of regret, recrimination, and the defeat of shame and blame.
We’ll need to hear and tolerate the diversity within ourselves, to recognize our own inner voices, identities, moods, to notice how fluid and ephemeral they are so that we can see and appreciate differences in others and use the practice of self-discovery to move beyond ourselves.
We’ll need to move beyond dualities — beyond either/or and then on beyond the simple corrective of both/and, move to true multiplicities of seeing and of understanding, multiple lenses that acknowledge how competing language games and inequalities of power and control create lived realities that may never even intersect unless we stretch ourselves to bring them together.
And this, I think — finally — returns us to Don Berwick’s charge.
Those of us whose primary work is outside the political realm have an essential role to play — in the civic spaces we occupy — stimulating deeper dialogues about diversity, working toward a greater capacity to harvest the richness in the differences that divide and yet enrich and define us.
I see this work as the most fundamental challenge to 21st-century leadership. And I see it at the heart of the question of whether we can craft more creative and affordable responses to the needs of the growing numbers of Americans living in Hubert Humphrey’s dimly-lit and dangerous spaces, in the dawn and the twilight, and the shadows of modern life.
And it is here, perhaps, that we do have our antidote to the hopelessness that killed Isaiah in our immense capacity as humans — under the right conditions — to find and awaken the best in ourselves and one another.
I hope so.