Emanuel, Ezekiel "Zeke" (2026)

BA: Good afternoon. Today is February 10, 2026. My name is Brittany Acors. I am a postdoctoral fellow in the Department of Bioethics in the Clinical Center. Today I have the pleasure of speaking with Ezekiel J. Emanuel. Dr. Emanuel was the first Chief of the Department of Bioethics at NIH and held the role from 1997–2011. He is now Vice Provost for Global Initiatives, the Co-Director of the Healthcare Transformation Institute, and the Diane v.S. Levy and Robert M. Levy University Professor at the University of Pennsylvania Perelman School of Medicine. He has written widely on such topics as research ethics, health care reform, resource allocation, and much more. Thank you for taking the time to talk with me today, Dr. Emanuel.

ZE: My pleasure.

BA: Just to start off, can you tell me a little bit about what your family life was like when you were growing up?

ZE: My family life? Three wild boys. We slept in the same room. Until I was 11 years old, roughly, we lived in the city of Chicago in a triple-decker, not far from the lake. I think we had three houses while I was growing up in Chicago, and then we moved to a northern suburb of Chicago called Wilmette, where we went to the local public grammar school. I went to the local middle school—junior high, it was called—and then I went to the public high school, one of the finest public high schools in the country, called New Trier West. What’s most unique is, in the 1960s and ’70s, we went on international airplane trips, which was highly unusual. My father was a big believer that the best education was travel. We spent summers in Israel, 1967–70. Then we went to Denmark and Norway in ’71. My brothers went back to Israel with my mom. I took summer school, and my dad and I went to Switzerland and France and Italy on a road trip for about three weeks together. This was pretty usual for our family. We weren’t rich, but my father was very, very dedicated to travel.

BA: What do you remember most? What stands out to you from those trips or what you learned from them?

ZE: I would say that one of the things that stood out most was the total freedom we had. [laughs] My mom was, I like to call her, the anti-helicopter mom. She would shoo us out of the house and say alright, go play, figure it out. For part of my life, we had a playground literally about 100 yards down the block, and we would go there. We would go across the street to a very large park near the lakefront. In Israel, we would go down to the beach and hang out at the beach and go swimming and stuff. We were entrusted to find our friends, play with them, negotiate, settle disagreements. There was a lot of effort that we had to come up with: how we were going to occupy ourselves, work out social interactions with friends when there were disagreements about what game we were playing and people committed fouls or made mistakes or what have you. It was lot of independence. Frankly, my mom even allowed me to take the Chicago subway system to the downtown library by myself and come back. I was responsible from a very young age, six years old, for my younger brother Rahm, going to school and bringing him home on the public bus—not school bus, public bus!—giving him the car fare and all. There was a lot more responsibility, freedom, and social interaction growing up than I think most kids get today. Probably one or two weekends a month, I would sleep over at someone else’s house or one of my friends would sleep over at our house, so that was very common. Pretty uncommon, I gather, today.

BA: I think that independence and negotiation and relationship-building skills are going to come into all three of your lives later on. I wanted to hear about your entry into higher education. You attended Amherst College, where you majored in chemistry, and then you went to Oxford University for an MSc in biochemistry. What motivated you to study science and to pursue a master’s degree abroad?

ZE: So first of all, I also did a lot of philosophy. I fulfilled all the requirements for the philosophy major at Amherst. While I was at Oxford, I did a fair amount of philosophy, even though the main objective there was to get a master’s degree and to have a research experience.
I did science in part because I was good at science. As I mentioned, I went to a very good high school. We had a fabulous chemistry teacher [Bob Koonz]. He really excited the kids about the subject and learning and made it seem very exciting. It was pretty rigorous. Every Thursday, we had a homework packet that was due. We had a test on Thursdays. And he was very encouraging of students thinking and putting to use what they learned. Similarly, I was reasonably good at biology, a little less good at physics. My calculus was OK, but not great. I did fine, but it wasn’t something I liked doing. At Amherst, I was really good in chemistry and did a lot of tutoring of other students. I would say two important things that are not appreciated. When I left high school, I graduated pretty high in a very large class, but I wasn’t number one in the class. No one said, “You watch that guy. He’s going to be great.” No one said that about any of the Emanuel brothers, “You watch them, you’re going to hear from them.” That wasn’t the idea. No one thought that was true. I was good in school. I did very, very well in school, but I was hardly, you know, someone picked out as going to make a big mark.

I think at college, I actually had one major deficiency. My high school was good, but it was not particularly good at teaching me how to write well. I didn’t write well, and I had a tutor for writing my first year who actually fired me, I was so bad. It wasn’t until my third year where one of my roommates said, “Listen, you talk well, but you’re terrible at writing.” He actually said, “We’re going to open a dictionary. It’s going to sit out open, and you’re going to have a notebook. Every word you don’t know, you’re going to look up, write down, and you’re going to review them and begin using them in your writing.” That was a real help to me. When I got to Oxford, my mentor who was running the biochemistry lab I was in said, “You have to write short. Americans can’t write long. You’re not Henry James. No semicolons or dashes. Ten words or less every sentence.” That was actually short sentences; very good to my writing style and actually very good to the way I speak. That was a boon. So, it took me a long time to learn how to write, and it was a real struggle. It’s one of the things I worry about students today, because they have all this help, like ChatGPT. They’re not working very hard or struggling very hard to learn something. I think that’s a real mistake.

BA: What drew you to philosophy while you were at Amherst?

ZE: Oh, actually, it didn’t start at Amherst. It started in high school. We had a “Great Books” English class for my junior and senior year. Probably one of the reasons I didn’t learn how to write, but I did learn how to read. We had, again, a fabulous, highly dedicated teacher, Raissa Landor. She cultivated a love of great books in me, reading Apology and Crito of Plato, reading Freud. We read a lot of great books. I really liked philosophy, so I took all the philosophy core classes [at Amherst]. At Oxford, there were a lot of great classes: Quentin Skinner, an expert in Machiavelli, gave lectures; Leszek Kołakowski, expert in Marxism and anti-Marxism, gave lectures; Charles Taylor was a professor and was lecturing on Hegel and modern ethical philosophy. It was a great moment for learning about philosophy.

BA: You kept up this combination of philosophy and science when you went to Harvard. In 1981, you started the MD program at Harvard, and then you also began a PhD in political philosophy there in 1984. Was that an unusual combination of degrees at the time? Why did you pursue both?

ZE: Well, first, I was a reluctant medical student. It was not my choice. I had lots of arguments with my parents. My dad was really insistent. He was a physician; he was an immigrant physician. I was first-born, and I was good in science, so it was overdetermined that I should become a doctor. I really didn’t want to become a doctor. I went to med school, and I hated the first year. Very hierarchical. Lots of memorization without a lot of critical thinking. Didn’t feel like I was using my brain very much. There were a couple of classes I liked, like anatomy, which I found fascinating. The summer between my first year and second year at medical school, I actually went down and did an internship as a journalist in Washington. I realized that I’m not as good a writer as the people who had been on school newspapers, I wasn’t very fast, and I didn’t like reporting on what was happening—I wanted to make things happen. I didn’t have a plan B, so I went back to med school. Fortunately, in the second year of the particular program at Harvard that I was in, kids were given a half-day off per week to pursue labs, and go into labs, and see which lab they wanted to go in. The people who were in my program were very good at science, and they were supposed to work in a lab. I didn’t do that. [laughs] It turned out that someone had arranged for me to be a tutor in the social studies program at Harvard, which is a program kids elect in their sophomore year. I was a tutor for a section. The course in social studies at Harvard is basically great books, from Thucydides to Durkheim; Hobbs, and Locke, and Kant, and Marx, and Hegel. It was great. I loved it, and I also loved teaching. I thought, “I’m really good at this.”

I decided that in my third year, which is a clinical year, I would apply to do a PhD. I was interested in bioethical dilemmas, particularly the fact that we did a shitty job of end-of-life care, resuscitating people who shouldn’t have been resuscitated. I thought I could bring my ethics skills to medicine and help. So I stopped medical school. I did fifteen months of clinical rotations, and then basically stopped, and went off, and did the PhD. When I left to do the PhD, yes, I was very unusual. Certainly no one at Harvard had done a PhD in political philosophy [as a medical student]. More importantly, the med school was not very supportive. They had money for MD-PhDs, but they did not support PhDs in the humanities or social sciences. They did get a grant from the MacArthur Foundation to support six people with PhDs in the “social sciences.” They did not deem my work in political philosophy to be a social science, so they did not support me. The Dean of Students basically said to me, “You’re going to work in end-of-life care. It’s a career ender. Medicine’s not interested in death and dying and improving it. We’re not going to stop you, but we’re also not going to help you.”

So, being pigheaded, I did it anyway. I think I turned out to be right and that person turned out to be dead wrong, and [they had] bad judgment about the future. Anyway, I had a much better time doing graduate work than I did in medical school. It was a great time. Then I did a fellowship. They had established a program in “Ethics in the Profession,” and I was invited to be in the first class. That was a critical moment for me.

BA: After you finished the PhD, did you finish med school simultaneously?

ZE: No. I just had to complete a few more rotations, so I did an odd rotation here and there. When the PhD was written, but I hadn’t been awarded my PhD—I still had oral exam and a few other things to finish—I started my internship. I got the MD in ’88, and I got the PhD in ’89. That’s basically the sequence. I went back to do an internship after basically being away from patients for nearly four years. It was a little crazy. [laughs] That’s why I asked to start my internship in the CCU [coronary care unit] because I figured even someone who was well-experienced, had gone straight through, and done a lot of rotations wouldn’t get anywhere near patients with recent myocardial infarctions without a lot of supervision. I figured, eh, I’ll get a lot of supervision, I’ll learn a lot, and then I’ll remember everything, like how to write a note, how to write orders, what medications. It all turned out to be true. [laughs]

BA: What was your dissertation about?

ZE: My dissertation was actually my book, the first book I wrote, The Ends of Human Life. It’s about how liberal values influence the kind of conundrums and dilemmas we have in medicine, particularly end-of-life care and allocation dilemmas.

BA: You were also in the first cohort of faculty fellows at the Edmond J. Safra Center for Ethics at Harvard. Can you tell me about that center, and what it was like to be in that first cohort?

ZE: In the ’87–’88 year, I was the first fellow. It wasn’t called the Safra Center at that time. It was called the Program in Ethics in the Professions. There were four of us in the fellowship: one from business, one from political science, one from law, and me, in medicine. One of those guys sort of dropped out. The business guy didn’t really attend, he had some issues, so there were three of us.

I learned a huge amount. It also allowed me to complete my dissertation writing and publish my first paper in the New England Journal of Medicine about the obligation to treat HIV-positive patients. It gave me a way of thinking about ethical dilemmas that turned out to be extremely helpful. It was a very wonderful bonding experience. It was run by Dennis Thompson, who at that time was a very important political philosopher about the ethics of government, but also a leading scholar on conflict of interest, not just in government but in professions generally. His way of thinking about, you know, what is the goal of a profession, and how does an action further or undermine that goal, was very important to my own thinking both during that fellowship and subsequently.

BA: Yeah, I can see that running through a lot of your work. You talked about how you chose the CCU internship, but you then went on to a fellowship in oncology at the Dana-Farber Cancer Institute and specialized in breast oncology. How did you choose that? What do you remember from that training period?

ZE: I chose oncology because it had everything. First, cancer was at the cutting edge of scientific research, and then, in particular, was at the cutting edge of molecular biology applied to medicine. Second, it had all the ethical dilemmas you could want. It had informed consent: did patients really know what they were getting into? It had end-of-life care, since about half our patients would unfortunately die. It had super expensive treatments—at that time, the big cost was bone marrow transplantation, about $100,000—and therefore big issues about allocating resources. I found that this was a crisis for a patient, and therefore raised all sorts of questions about the values, what they should value. I found that to be a moment that was challenging and interesting to help patients through. So it had everything that appealed to me. I will say that at least one of my mentors, Tom Delbanco, was horrified by the choice. He was a big proponent of primary care, which I am too, but it wasn’t the right choice for me.

The Farber turned out to be a great place. While I wasn’t doing the usual—I was out of step with everyone who was going into labs and doing the molecular biology part—I started Ethics Grand Rounds there, and everyone showed up. Everyone was keen. We were talking about these cases. I was able to publish those Grand Rounds in the leading clinical oncology journal. It gave me the opportunity to pursue end-of-life-care research. There was a lot of flexibility for me and a good environment for me to just put my head down and publish a lot of papers.

In my first year, while we were doing clinical rotations, everyone got a month off to again try out the lab. I took that month off. I wasn’t trying out labs, because I wasn’t going into a lab. I wrote one of my most important papers, “Four Models of the Physician-Patient Relationship” (1992). It’s still around. I was in Germany this past summer, and the students said, “Yeah, we learned your four models of physician-patient relationship. We read that paper.” And I was like, wow, that’s 35 years later. That’s not bad to have a paper that is published in a medical journal, that’s not a scientific breakthrough, still being read and used, and students learning it and referring to it.

BA: That’s a pretty huge impact. What did you do after the fellowship at Dana-Farber?

ZE: Well, I just seamlessly fell into instructorship/assistant professorship and did the usual. Of course, getting funding for bioethics is not easy and was really hard there. NIH was not interested in end-of-life care or euthanasia and supporting it. But the American Cancer Society was, so they gave me a fellowship. They supported me with some grants to look into euthanasia among cancer patients, and it turned out to be an incredibly productive time. We also got a grant from the Commonwealth Fund to look at end-of-life care among patients who were terminally ill, what their experiences were. I was there from July 1st, 1990, to 1997—about a year and a half as a fellow, then instructor, then assistant professor, and I was in the process of being promoted to associate professor when I left to come to the NIH.

BA: Now we’ll get into that shift to the NIH. In 1995, Dr. John Gallin hosted the “Conference on the Future of Clinical Bioethics at the National Institutes of Health Intramural Program,” which led to the creation of the Department of Bioethics in 1996, although it was based on some earlier foundations here. Can you tell me about the search committee and interview process that led to you being hired as Chief of the new department?

ZE: No, I can’t tell you about the search process. I can tell you about my limited experience. I was invited in. There was a panel of about 10–12 people. They interviewed me. I guess I passed muster, which is a little surprising, upon reflection—not at that moment, but upon reflection. I had not written a single paper, not one, about research ethics. And this was clearly a research ethics job, because that’s what we do at the NIH. So, it was a little surprising that I got past that stage.

There were three finalists, as I understand it, for the job (I’ve never tried to verify it): Jonathan Moreno, who was at UVA [University of Virginia] or downstate at that time, I can’t remember which one; Bob Levine at Yale, who had written the book on research ethics; and me. I was clearly the youngest. I was clearly the most junior. I wasn’t even, at that time, 40 years old. And John Gallin and I, I have to say, hit it off. I don’t want to speak for John. He was a wonderful man. I walked into the office for my final interview with him. The committee recommended, I guess, the three people, and I had a final interview with him, and then he was going to make a final choice. He basically said, “Look, we have something in common.” I said, “Really?,” since he was one of those molecular medicine types who was working on a rare immunological disorder [chronic granulomatous disease]. Yes, I had done some immunology, but that wasn’t what he said. “We both went to Amherst College.” And I said, “Wow.”

I think he had some faith that I could lead something and create something, and that I had a streak that allowed me to take something new and build something. I had been extremely productive. I was also a practicing oncologist, in that I saw cancer patients. So I checked off a lot of boxes, and I could relate to the doctors there. I was lucky enough to get the job.

I spent the first year, ’96 to ’97, commuting. I had a three-city commute, because I was still quasi at the Farber, and I’ll say why that happened. My wife [Linda L. Emanuel] and kids had moved to Chicago because my wife got a job as the AMA [American Medical Association] ethicist. So, I was commuting between the three cities. It was a little insane.

The main reason I didn’t take up the job immediately was that I was appointed to the Bioethics Commission under Harold Shapiro, and you couldn’t be a government employee and on the Bioethics Commission. We changed that—I changed that rule, but that was the rule then. I maintained Farber as my primary affiliation and was a consultant to the NIH, but I did a lot of work. Harold Varmus [former NIH Director, 1993–1999] had me in to do some work. That was also the moment of controversy around the maternal-fetal HIV transmission studies in Africa, and I advised on that and worked on that. There were a few other, you might call them, “scandals” that I was working on as a sort of consultant, and I was frankly thinking about how to structure the department.

BA: Dr. Gallin said in an interview that when he hired you to help build the department, you asked what you had to do, and he said, “It’s easy. Just build the best bioethics department in the world.” What was your vision for how to accomplish that, and what were you thinking about in the year before you came here officially?

ZE: When I went to the Farber, I had figured out that bioethics is often a poor stepchild. It’s not often seen as the core of what a medical institution, an academic center, or a medical school is doing. That’s a mistake in my view. But there is a very clear way that faculty are evaluated in medical schools and academic health centers. That is, are you publishing? Are you getting recognition? Are you in the top journals? So my vision was, whatever we did, we had to aim to get published in the New England Journal, JAMA, The Lancet, Annals, Science, whatever the top journals were. We had to make sure that our work, whether conceptual or empirical, was the best and could get us into those journals. We would then be recognized, and maybe even admired, by the scientists, because we were publishing in the journals they wanted to get into as well. If there was a “secret”, the secret sauce is, look, we’re going to succeed in the biomedical literature, and we’re going to get recognition by that. The second thing was quite clear: we had to work in research ethics. Now, when I came to the NIH, as I mentioned, I had done zero research ethics. Literally zero. So I had to sit down and read the Declaration of Helsinki. I had to read the Common Rule. I had served on an IRB [institutional review board], but I’d never looked at that. No one ever said anything. Everyone at the NIH was very familiar with 45 CFR 46 [Code of Federal Regulations], of which I had no idea what the hell they were referring to, and the Declaration of Helsinki—I’d never read it, even though I had been a bioethicist working on bioethical issues.

One of the advantages of coming to something with fresh eyes is you can realize all the problems. When I came to the NIH, I said, oh, the research ethics framework is there, and it’s really about applying it, etc. But once I got there, I was quite clear to me the framework was broken. You read the Declaration of Helsinki, and the first thing that comes to you is, the damn thing is incoherent. The early versions are written higgledy-piggledy. They’ve got clauses or provisions that have no logical flow to them and don’t make sense. Really, a lot of lawyers got at the code and hadn’t thought ethically about what was going on.

It allowed me to step back and write one of the most important papers we ever wrote, “What Makes Clinical Research Ethical?” [Emanuel, Wendler, and Grady, 2000], and try to work out a framework. I think one of my talents is creating an ethical framework, figuring out what the principles are that are going to structure the thinking about an issue. That’s probably the most important thing I learned from that program in Ethics in the Professions at Harvard: you have to have an ethical goal, or you have to have a framework, and you have to use that framework to think through problems. You always return to your fundamental underlying values in thinking through what the right solutions are. So that’s what we did in that paper—said, all right, what are the fundamental principles you have to fulfill, and if you fulfill that, the research is ethical. Once we laid out seven and then eight principles, which then gave us an opportunity to delve into various topics that had been unresolved or controversial and use the structure we had developed to illuminate them and to resolve the problems.

For example, Christine [Grady] and our first fellow looked at payment—what do the principles say about payment? We looked at Phase I oncology trials, which had been surrounded by all sorts of controversy because patients could die on the trials. We ended up analyzing: how do you assess risks and benefits? How do you balance them? What does that actually look like? What are the risks of everyday life? You know, no one had actually quantified them, and we went out [and did that]. That really spawned a whole way of thinking about trials. Of course, there were international trials, and we collaborated with NIAID [the National Institute of Allergy and Infectious Diseases] to develop a whole educational program. We went around the world, training people who got NIH grants or fellows how to do ethical research, trying to improve their ethical analysis of research trials. Lots of things spun out of that framework, and it became incredibly productive.

Let me say one other thing. When we started, the infrastructure was not zero, but almost zero. There were two fellows. Dave Wendler was one of them. [Evan DeRenzo was the other.] They were fellows, but on the other hand, they were doing everything that faculty should be doing. They were doing research and publishing; they were offering consults. I sought to restructure the program. Dave stayed, and Evan left. Christine was the deputy director. One day, we got a call. We were sitting around, I think it was teatime or something, and got a call from a kid, a senior at Dartmouth. He said, “I noticed that there’s this NIH bioethics program. Do you have a fellowship for kids coming out of college?” I looked at Christine, and I said, “I don’t know. Do we have a fellowship?” [laughs] We said, “Listen, we don’t know. We’re going to call you back.” Christine and I talked about it and if it would be good. I went up to talk to John [Gallin]. I said, “John, someone asked if we have a fellowship. What do you think?” He said, “Look, one of the primary things we do here at the NIH is train people. You can develop a fellowship and have the positions to train fellows.” It was literally an external call. It’s not that I had thought through a whole fellowship. I had never mentored someone. I mean, I had students when I taught, but I never mentored people. So we called the kid back. It turned out to be Neal Dickert. We called him back and said, “Yeah, we’re creating a fellowship. You wanna be the first fellow? Send us your CV so we can just make sure that we’d like to have you.” And we were off to the races.

We had some post-doc fellows, and then we had pre-doc fellows. The pre-doc fellows came for two years, and then they typically went on to med school or law school. That was a typical path; there were ones who did other things. And it was fabulous. You got these eager people, and literally they were super smart, and all you had to do was be with them. Our fellows published first-author papers in the New England Journal, published in The Lancet, published in JAMA, every which way. Some of the great papers I’m on, [our fellows] were the intellectual originators, and part of what I did was just massage them: this is how you write a paper for getting into the New England Journal, or whatever. We were so lucky that we had this pre-doc fellowship, because the most impressive people came through that program. I think we made their career, and they made our career. We also had a lot of philosophy near-misses, I call them—people who got on the job market but didn’t get a job offer, came to us focused on philosophy and bioethics, and then went on the job market and all got jobs. It was a very good training ground for them, and also good for us. We got some really terrific people, making some of the best contributions. Probably I’m going to exhaust you in filibuster here, but one of the things that I said to John Gallin when I took the job was, listen, you’re giving me certain number of FTEs [full time equivalents]. That’s the currency at the NIH. I said, I don’t want to hire only faculty. I would like to keep one for a visiting scholar, because I think we could become ossified too easily. I’m the kind of person where I like people to disagree with me. I know what I think. I don’t need people to echo my opinion. Sometimes it’s useful to have people who can help me work out what the right opinion is or why my opinion is the right one. But I tend not to like sycophants, I hate that. I like people who are going to argue and challenge me. I wanted someone who would come in every year, new, fresh to the place, so we wouldn’t become ossified, and stir the pot. We could buy out their salaries, so that they wouldn’t lose any money, and we would get the best people—whoever we offer the job would say yes. We started out with someone from Georgetown, Maggie Little. We had fabulous people. Three of them stayed. They came as fellows, and then we convinced them to stay. One ended up going to Duke [Gopal Sreenivasan]. Alan Wertheimer had retired, but I said, Alan, come out of retirement. Just spend a year commuting between Burlington, VT, and here. And then we got him to stay and make fantastic contributions. Dan Brock, who was a university professor at Brown, came, and he stayed a few years until Harvard poached him. I think he also found the pressure of the NIH not quite to his metabolism. John was very generous there. He encouraged us to have the fellows, that was his idea, and he allowed me to have this visiting scholar position. It really worked fabulously.

BA: Can you tell me about how you grew the permanent faculty from you, Christine, and Dave, to a much bigger department by the end of your term?

ZE: Yeah. Part of it was partnering with other institutes to develop [bioethics positions in them]. The Genome Institute needed a bioethicist, so we ended up working with them and hiring two bioethicists, Ben Wilfond and [Sara Chandros Hull]. We also figured, since we were doing global stuff, we needed someone more in the global space, so we hired Reidar Lie from Norway. We figured out what was an area that we were missing, and who’s around. There was some serendipity. I mentioned we brought Alan Wertheimer in, who’d written books already on consent, exploitation, coercion—key concepts in bioethics. Part of the idea was, Alan, you’ve got all these great ideas about these issues. Just apply them to health care and medicine! He hadn’t thought of that, but I think he was really excited about the possibility—we made it exciting for him.

We began getting a lot of people who were around, like Frank Miller, who done a lot of great work at NIMH [the National Institute of Mental Health]. I was interested in his work on mental health and other kinds of research. He turned out to go well beyond that. Frank is a very good example: Frank and I didn’t agree on a lot of things. There were many, many things we didn’t agree on at all. But we ended up writing together, partially because when we did agree, we were able to develop really strong, careful, precise arguments. I think there were a number of people who were around [and that’s how we grew].

I haven’t spoken about this, but I did—and this was definitely me—two things that were really important to create a culture at the department. One is, I asked John if we could redesign the space he had given us. He had given us what I can only call a rabbit warren. There was a large hall with a set of rooms off to one side and a set of rooms off to another side and a turn, and there was no way you would have a coherent department with the way it was designed. So I told him, listen, if I could move it around, we could reclaim that hallway and actually make it useful space. Since space was the coin of the realm—space was limited, everyone was fighting over every square inch—that appealed to him. Plus, he had a son who was an architect, and so he had an appreciation for architecture. What I didn’t know at that time was that he had also built his own house, so he had an appreciation for design and architecture, which most scientists lack totally. And he allowed me to do it. We created what I think turned out to be the ideal academic space: we had a big common room, which was a library with a library table in it, and all the offices spun off that room. People could retreat to an office and work, but there was common space where people would be forced to be together.

[The second is,] every day I instituted teatime. I had studied in Oxford, and one of the great institutions in Oxford is high tea. In the biochemistry department, high tea consisted of paying five pence for a cup of milky tea and one biscuit. Well, we embellished that a little bit. We would have tea, and someone was responsible for the week. There would be fruit, and cheese, and some sweet, cake or crackers or cookies or something. Depending on who did it, they got more elaborate. One of the visiting scholars complained about the teas, that he had put on fifteen pounds in his first six months at the department because of teatime. But it allowed everyone to get together between 3:30 and roughly 4:15 for 45 minutes and talk. Now sometimes we were just talking about movies or politics or other crap, but a lot of times, either papers got worked out there or an idea happened and two people would go off and write a paper. It made it very communal and brought people—I won’t say forced, but more or less required people—to come together and share. There was, I think, a very good communal feeling and warm feeling to the department. I think teatime was a critical institutional change, or just difference with America, that really became common. We also had a tradition of inviting people who worked for other parts of the NIH to come and spend a teatime with us, and we would talk with them. It was a very good way of establishing a very generative and warm environment and culture.

BA: I agree. It’s a tradition that’s still alive and well, and I’m the host this week, so we’re doing Valentine’s tea.

ZE: Yeah, good, good, good.

BA: Why did you leave the department in 2011, and what was next for you?

ZE: I was seconded to the White House to work on health care reform. My research changed in about 2003/2004, when I realized I’d said almost everything I wanted to say about research ethics. I thought I’d move to another unsolved problem, which was healthcare reform, and also turned out to be allocating resources, which I didn’t plan when I decided to shift my research. Obama won [in 2008] on a plank of reforming health care, and I was fortunate enough to be asked to go to the White House and work on that. I spent two years there working not just on health care reform, but on global health, revising the human subjects research regulations (45 CFR 46), working on redoing the food pyramid into a plate, and working on the First Lady’s “Let’s Move” initiative. I had a lot of things that I was involved in. Frankly, at the end of two years, I came back. There were changes at the OMB [Office of Management and Budget] and other places. Christine had become the Acting Department Chair. Francis Collins, who was head of the NIH, called me in and basically said, so when are you going? I was a little taken aback because I had been at the NIH [awhile]. I’d been incredibly productive, I think. I don’t know what I averaged, but something close to 15 papers a year, in top journals. We’d been renewed three times since I was there, or four times, I can’t remember exactly. I said, all right, I’ll look around and see what’s available. And I looked at five institutions. I had very good offers from both Penn [the University of Pennsylvania] and NYU [New York University] Law School, ironically enough. NYU Law School realized that, with health care reform, health care was going to become way more important and create lots of jobs for lawyers, but no law school in the country had a very good health law program. The dean at that time [Richard Revesz] had invited me up for the winter/spring semester of 2011 to teach a law class, which was a lot of fun. I’d never done anything like that. It was pretty tempting. He said, “Listen, we can go out and raise thirty or forty million dollars. You’ll have great center. You’ll be able to do whatever the hell you want. You’ll really affect the law.” It was very tempting. Plus, it’s in Washington Square Park in New York, and it’s like, ah, the West Village. But Penn was more interesting to me because it was a university-wide program that I could create. It was an administrative job, and I did want to create a program that would stretch between the business school, the law school, the medical school, and Penn had that opportunity. It also gave me an opportunity to build another department that was both bioethics and health policy, so that was super exciting.

BA: And bridging those fields, business and law and medicine, goes all the way back to your Ethics in the Profession fellowship.

ZE: Absolutely, 100%. My main teaching now when I’m at Penn is at Wharton, the business school, although one of the things I required there was that I could have students from all across the university. So I have medical students, law students, engineering students, and undergraduates. Also, medical fellows often pop up—they’re in the lab doing their research, and they come and take the class. It’s very satisfying in that respect. Plus it also allows me to do other teaching. In the college, I teach a course on how Washington really works. I developed a course which is on Coursera on Ben Franklin, which I wouldn’t have done if I had been at the NIH. It allowed me to, unbeknownst to me, explore new opportunities and new intellectual paths, so it was good.

BA: Just a couple big picture questions in our last few minutes here. Do you have any particular memories that stand out from your time in the Department of Bioethics?

ZE: Oh, [laughs] lots and lots of memories. I will tell you one of the most important things for my academic career. We hosted Ethics Grand Rounds [at NIH]. I brought [that idea] from the Dana-Farber Ethics Grand Rounds to the NIH. Once in 2003 or 4 or 5 (I think 5, but maybe 4), HHS [the Department of Health and Human Services] had come out with a report on preparing for a flu pandemic. We held a panel that talked about the report, and then there was question-and-answer, which was the usual thing we did. The panel talked about the prioritization, how we wouldn’t have enough flu vaccine. You’d probably need 90 to 200 million vaccines right out of the box. You couldn’t produce that overnight—we would have to prioritize them. They [recommended that we] prioritize old people, over 65-year-old people, and I knew that was wrong. I knew in the 1918 flu pandemic, younger people died disproportionately high. As I was walking out of that Grand Rounds—I didn’t host the Grand Rounds, Dave Wendler was the host of the Grand Rounds, that was his job—I was by Alan Wertheimer, who by that time was in the department. I said, that just can’t be right, to prioritize old people. Out of that simple exchange between us that day, walking up the stairs out of the auditorium, the Masur Auditorium there, we developed our paper on why young people ought to receive priority, especially in a flu pandemic that is much more likely to be disproportionately targeting young people. That got published in Science, in the policy forum there. Lots of controversy, because it was critical of the HHS report. So here I am in the department, and we’re criticizing our bosses, basically. That led to developing this whole framework for thinking about allocating resources. It ended up with a major paper. Govind Persad came on it thinking about the allocation of organs for transplantation. We laid out the framework perfectly. It led to a lot of criticism of me with our whale graph for prioritization [a term Zeke coined for Figure 1 in Persad, Wertheimer, and Emanuel 2009, because it looks like a whale], but it’s the right framework for thinking about it. That framework became the one almost every country ended up using internally, or some modification of it, for allocating COVID vaccines.

The allocation of scarce resources is one of those areas that had been fallow for decades. No one could figure out what was the right way to think about this. I think we cracked a very, very big nut, again, just walking out of the auditorium, knowing that what someone presented was wrong, and then trying to work out what we thought the right answer was. Incredibly powerful. Same thing happened with placebo-controlled trials where Helsinki and the WHO [World Health Organization] had gone on to the wrong answer: never do a placebo-controlled trial when you have a standard of care. There, Frank Miller and I, who, as I said, agreed on almost nothing, said, that can’t be right. There are some cases where you can do it, and it’s perfectly ethical to do. We ended up writing a very important New England Journal paper on that.
The serendipity of breakthroughs is why [it’s important to have] an area where everyone’s constantly talking to someone else and coming up with what they’re thinking about. We had a fellow working with us, Jon Tilburt, a physician who was, I think, a Hopkins house officer or something. He was interested in alternative medicine, and he was going to do a survey on alternative medicine. We came up with an idea: how often do doctors prescribe alternative medicines that they think are not effective, just to placate patients—basically placebo? That turned out to be probably the most publicly cited paper I’ve ever done. He was about to do a big survey, and we just added, I don’t know, five questions or something. It turned out to be a huge hit, a huge, important finding about how often doctors actually prescribe things as placebos. Sometimes just vitamins, but sometimes serious medications. That serendipity, that we were open to possibilities and jumped on possibilities that were going to be generative—that was great, in my time at the NIH. Also, the ability to create a culture where everyone was working together. New fellows would come in, and we weren’t shy about giving responsibility for major papers to pre-docs. This happened over and over. Govind, when he was a pre-doc, wrote this great article in The Lancet. Lindsay Hampson, who’s now at UCSF as a surgeon, did a survey of cancer patients about their views of their doctors’ conflicts of interest. I got a request to give a talk at a major cancer meeting on conflict of interest, and I was like, “I can’t make it. Lindsay, why don’t you go?” There she is, a kid one year out of college, talking to 400 oncologists. We had no problem doing that. It was insane, probably academic malpractice, but she was a smash hit because she was talented. We just had a lot of talented people, and we were not shy about putting them out there and letting them take huge responsibilities, way more than their age.

BA: What do you see as some of the greatest challenges and opportunities for bioethics in the next five to ten years?

ZE: Well, I think AI is going to be a huge problem. Just no two questions about it. We also have huge problems about costs for and allocation of gene therapy, cell therapies. We’re moving into the era of enhancements and prenatal genetic modifications. Those are big issues.

BA: I could have asked a million more questions, but we are at time, and I want to be respectful of your time. Is there anything else you’d like to add or any questions you wish I had asked you?

ZE: No, I think that you did a very good job. I really appreciate it.

BA: Thank you so much for taking the time to speak with me.

ZE: No problem. Take care.