What is needed, however, isn't just that people working together be nice to each other. It is discipline. Discipline is hard--harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can't even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.

One of the reasons people might be fallible, why we might fail to do what we try to do isignorance, that we have a limited understanding of the laws of the world - the physical laws that govern the world and of all the particulars of the world upon which those laws work. And then there's ineptitude, meaning that the knowledge is available, but individuals fail to apply it correctly. The third source is "necessary fallibility." That is, we're never going to be omniscient, there is some knowledge that we will simply never achieve, and there are limits to what we will be able to do.

I think the extreme complexity of medicine has become more than an individual clinician can handle. But not more than teams of clinicians can handle.

You want to ensure people can do it right 99 percent of time. When we have to fire one of our surgical trainees, it is never because they dont have the physical skills but because they dont have the moral skills - to practise and admit failure.

In the end, people don't view their life as merely the average of all its moments-which, after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens. Measurements of people's minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence. A seemingly happy life maybe empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves.

If the conversation people think is coming is the 'death panel' conversation, that's a total failure.

This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong.