It was supposed to be a good day for Bill Nelson, a day of congratulations for a job well done. He was waiting in a ballroom of the Palmer House, getting ready to deliver another talk on medical ethics. This was back in 1987, when Nelson was serving the Veteran’s Administration as the chief medical ethics educator. He had just helped to draft the agency’s first policy on “Do Not Resuscitate” directives, the orders that allow elderly or seriously ill patients to forego lifesaving CPR. The new policy was the V.A.’s first foray into the contentious issue, and it had gone well enough that Nelson had been asked to deliver the keynote address at the annual meeting of the heads of the one hundred seventy-one V.A. medical centers across the United States.
The problem came when Nelson heard how he was being introduced to the high-powered audience. It began with the usual listing of impressive credentials that speakers expect to hear before being called to the podium. Then, to really heap the praise on Nelson, the moderator began to celebrate the fiscal benefits of the new DNR policy. He explained that by reducing the number of very sick patients clogging the costly beds of intensive care units—patients who stood little chance of living for long in any case—the medical centers were saving precious budget dollars. It was all thanks, he suggested, to the policy that Bill Nelson had helped to craft.
“I remember being just stunned as I walked to the podium,” Nelson says. He felt proud of the policy for many reasons, but its cost-saving implications for hospitals were not at the top of the list. “I had prepared a speech, of course, but I threw my notes away. Instead I told the audience, ‘That is not why we’re doing this.’”
Nelson said he thought saving money was great, especially if the assembled medical directors used those resources to improve care elsewhere in their hospitals. But he insisted that the new policy was not about cost-savings. It was about patient autonomy and self-determination.
The spontaneous lecture was classic Nelson. In demanding not just ethical behavior but also ethical reasoning, he was being typically scrupulous. In promising that ethical thinking brings real benefits, he was being typically pragmatic. And when he made a mordant joke about whether he might be due a cut of the budget windfall that the new DNR policy had produced, he was being typically Nelson. It takes a certain kind of guts to go for laughs with an audience that is expecting only hectoring and scolding.
A distinctive mixture of clarity, pragmatism, and sly humor is the basic recipe Nelson has deployed throughout his long and distinguished career in medical ethics. It is the approach he took at the V.A., where, as chief of the ethics education service of the National Center for Ethics in Health Care, he crisscrossed the country trying to sell the value of ethical thinking to budget-squeezed administrators with eyes on the bottom line. It was not an easy sell, and the V.A.’s executives certainly got to see a lot of Nelson. When he retired from the agency in 2003 after twenty-eight years of service, his colleagues presented Nelson with a map of the United States studded with stars denoting locations he’d visited. The legend read, Where Hasn’t Bill Been?
Nelson has been speaking to doctors, medical students, and hospital administrators about the practical benefits of ethical thinking for decades, and in all that time, what he likes to call “the why question” has seldom been far from his mind. For Nelson, it’s not enough to do the right thing. You have to do it for the right reasons.
These days, he carries his message to the medical students he teaches at Dartmouth College and New York University, to the undergraduates he teaches at Elmhurst during January Term, and to the hospital CEOs he meets in his work as a consultant to the American College of Healthcare Executives.
To Nelson, ethics is not a theory; it’s a basis for living. “No one dares to say ethics is unimportant. That’s like saying your mother is unimportant,” Nelson says. “But how important is it to you? How much effort do you, as a hospital CEO, put into demonstrating that it really is important?”
With the executives (and even with some of the students) he meets, Nelson has learned to appeal to his listeners where they live, in their wallets. “For a lot of CEOs, the annual bonus is tied to their patients’ satisfaction scores. We know that when you act ethically you’ll have better patient satisfaction scores.” Nelson asks them: “‘Do you want your bonus? Then you had better pay attention to ethics.’ That really hits them between the eyes. I’m game to do that.”
“I’m not saying that’s our goal,” he adds quickly. “Our goal is to do the right thing for the right reasons. But the bottom line is: ethics is good business.”
Over the past few years, Nelson’s pitch has become increasingly familiar to Elmhurst students. He hosts undergraduates for week-long “shadowing” experiences in New York or in Hanover, New Hampshire. The students accompany Nelson on his daily circuit of professional obligations and meet his colleagues.
Throughout the sessions, Nelson takes pains to make sure that the emphasis is not only on the esoteric but also on the practical. Jen Batey, a biology major, spent a week shadowing Nelson last spring. Batey met with a neurologist who was consulting with the Vatican on end- of-life issues. He also met with a general practitioner from rural New Hampshire who tended to everything from births to broken limbs.
Larry Carroll, executive director of Elmhurst’s Center for Professional Excellence, helps arrange the shadowing experiences. “The students aren’t just sitting there and watching,” he says. “When they’re sitting in on meetings, he’ll call on them, ask them what they think, draw them into the discussion.” For the past two years, Nelson has come to campus each January to deliver his brand of ethics education. He leads a J-Term class called Philosophy 316: Ethical Aspects of Health Care. It’s become a must-have for students in majors like nursing or biology who are preparing to work in health care. The class has a maximum enrollment of twenty; a handful of disappointed students are left on the sidelines each January. “As much as students clamor to get into this class, I’m not sure they feel that way when it’s over,” he says. “They probably want to get out, because I push them.”
Nelson grew up in Wheaton, where he was a standout basketball player. He enrolled at Western Illinois University and played as a freshman there. In 1966, unhappy and unsure about his path in life, he transferred to Elmhurst, where he went out for the football team.
Nelson had never played anything but sandlot football, but he quickly established himself as an excellent receiver and defensive back for the Bluejays. He says he never got used to the hard hitting, though. “I remember once, after I made a tackle, I helped my opponent up, almost as if to apologize,” Nelson says. “My teammate, a linebacker, came up and grabbed me by the scruff of the neck and said, ‘What are you doing? You don’t apologize!’”
Basketball remained Nelson’s main athletic passion, and he starred on the Bluejays varsity. But even the game he had always loved was starting to seem less important to him. It was a time when contentious national issues—the war in Vietnam, civil rights—were swirling around the campus, and Nelson became increasingly absorbed in them. He started questioning what he wanted to do with his life.
Then he met Ron Goetz. The longtime Niebuhr Distinguished Chair of Theology and Ethics at Elmhurst, Goetz had studied at Harvard Divinity School and was known as a fierce defender of ideas who demanded intel- lectual rigor from his students. Nelson switched his major from history to religious studies and became particularly interested in ethics.
“The thing about Goetz is that he wouldn’t accept mediocrity,” says Nelson. “He was the first one to help me understand the importance of ethics in real life. He could be eccentric and I had never met anyone like him. We became great friends. My senior year I would hang out at his house and we had long conversations about the role of the church and religion and ethics in shaping the discussion of what should be done in the world.”
Knowing his student’s reputation as an athlete, Goetz liked to challenge Nelson to games of one-on-one basketball in the College gym. “He was such a dirty player,” Nelson remembers fondly. “He’d push and shove, put his head down and just rush at me, and if I tried to call a foul, he’d say, ‘You wimp!’”
Inspired by Goetz (at least oΩ the court), Nelson decided to go on to divinity school. After earning his degree at Andover-Newton Theological School in Massachusetts, he started a two-year residency at Dartmouth. He split his time between the chaplaincies at the college and at the medical center. Nelson assumed that the intellectual life of the campus would most engage him, but he found himself increasingly intrigued by the hospital.
His time at Dartmouth coincided with an explosion in interest in bioethics. Nelson was asked to lead a course in medical ethics at Dartmouth’s medical school. He eventually was recruited to lead the school’s program in medical humanities.
In 1991, Nelson became the chief of the ethics education service of the Veteran Administration’s National Center for Ethics in Health Care, which he had helped to start. The V.A. is a sprawling health-care system, the lar- gest in the United States, and the second largest agency in the federal government. Nelson spent the next twelve years making the seemingly endless circuit of V.A. hospitals, auditing, advising and establishing ethics committees.
He attacked the job relentlessly. “That’s where I became interested in organizations and systems,” he says. “We sometimes think of ethics only as, ‘Should this individual be on a respirator or not?’ But the more challenging issues are the macro issues: How do you encourage ethical thinking in a system?”
For Nelson, ethics must be integrated into an organization’s very fabric, not isolated in a silo-like ethics department. “In medical school, for example, it’s fine to have ethics classes. But we should have ethics training in all classes, so that even a class in cardiology or oncology has an ethics component.” In making his argument, he complements idealism with pragmatism. “What I’ve tried to do is make the business case for ethics. Even if you’re all about the profit motive, if you don’t do it within an ethical framework, you’re not going to be very successful. That’s the bottom line.”
Is anyone heeding medical ethicists like Nelson? The health-care industry, after all, has not lacked for fresh ethical outrages in recent years. But that’s not to say that the ethics reforms of recent decades have not had a dramatic impact on the way health care is delivered in the United States. Nelson had an opportunity to witness the progress the field has made when his eighty-six-year- old mother, Evelyn, experienced her final illness last year.
Nelson had seen his mother contend for years with heart disease and diabetes. When her medical problems escalated, she began talking with her family about how she wanted her medical care handled once she became irretrievably ill. She prepared a living will and wrote Nelson and his father letters as a way of expressing her love and saying a formal last goodbye. During one hospital stay, her system went into complete failure. Her condition now irreversible, she was disconnected from her respirator and died with her family at her side.
“Afterward, I thought, this is something we’ve been propagating for twenty years: We should be able to say goodbye in a caring, compassionate manner,” Nelson says. “Twenty years ago, you couldn’t say, enough is enough.” His mother, he knew, had that opportunity. “This was the right thing to do, and it was done right. It was clear to me then how much impact our work has had on the way health care is delivered.”
It is harder to know how deeply what Nelson calls “the business case for ethics” has penetrated the executive suites. Recent scandals at HealthSouth and other companies leave few hopeful about the state of ethics in corporate America. But Nelson says the scandals have made it easier for him to make his case, by shining a spotlight on the ramifications of unethical behavior and by serving as cautionary tales.
In any case, Nelson is determined to keep driving home his points. He continues to shuttle between Dartmouth and New York, with a stop each January at Elmhurst. Add his role as a consultant to health-care executives and his obligations keep him on the road so often that one of Nelson’s colleagues teases him about what might happen if he doesn’t climb to 35,000 feet every few days.
Nelson’s J-Term class met this year in a room on the second floor of the Schaible Science Center. It’s a standard classroom, equipped with the usual “smart” technologies and some old-school periodic tables on the walls. But it’s a seemingly unlikely location for a philosophy class—they usually meet in Hammerschmidt Chapel. Nelson wasted little time in telling his students that he thought the class’s location was fitting.
“Maybe it’s appropriate that we’re not over in the chapel. This isn’t going to be an esoteric class,” he said. “We’re going to be dissecting the kinds of cases you’ll encounter as professionals. The goal is to give you the practical skills to handle them.” Then he had the students stand and rearrange the seating into a discourse-friendly circle.
Much of the first class was spent discussing the strange case of Dr. Michael DeBakey, the pioneering heart surgeon who suffered an aortic aneurysm last year and whose doctors overrode his previously stated preference to forego surgery. The case was complicated by DeBakey’s age (he was 97), his celebrity, and the fact that he was admitted to the hospital anonymously, keeping insurers in the dark. It gave the students plenty to discuss, and with Nelson prodding them, the debate was lively.
“He just loves the idea of discussion,” Larry Carroll says. “He’ll make a statement, then have the class challenge it. He shows the same kind of respect for undergraduates that he does for medical students and professionals. He expects rigor.”
The work for Nelson’s students begins even before the class meets for the first time. He e-mails his syllabus ahead, complete with the first reading assignment, so the debate can begin on the first day of class, with no time wasted on preliminary niceties.
Nelson has such an amiable manner that you don’t really get a sense for how driven he can be until you consider the schedule he keeps for himself. Last year, when Elmhurst awarded him an honorary doctorate, he had to hustle back from a hiking trip in Peru to make the ceremony (just barely). Once an avid marathoner—he has completed eleven of them, with a personal best time of 2:54—he now settles for hundred-mile bike rides through the mountains of New Hampshire. He started biking when friends invited him along for a casual ride. Chagrined to find himself unable to keep up, he was soon training diligently. “I’ve wanted to be the best I could possibly be at everything I did,” he explains.
Like the confused undergraduate he once was, Nelson says he is “still struggling with what I’m going to do with the rest of my life.” The struggle intensified after his wife, Ginger Risco, died in the September 11, 2001, attacks on the World Trade Center. Nelson got to know the families of other victims. He saw how each handled their grief—and their survivors’ compensation—differently. Some indulged themselves; others threw themselves head- long into acts of altruism. Nelson kept working.
“To be blunt about it, I don’t need to work anymore,” he says. “But it’s what I do. It’s a way for me to make a difference.”