Barron H. Lerner - The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics

BEACON PRESS

Boston, Massachusetts

www.beacon.org

Beacon Press books

are published under the auspices of

the Unitarian Universalist Association of Congregations.

2014 by Barron H. Lerner, MD

All rights reserved

Printed in the United States of America

This book is printed on acid-free paper that meets the uncoated paper ANSI/NISO specifications for permanence as revised in 1992.

Text design and composition by Kim Arney

Frontispiece photo Barron H. Lerner

Library of Congress Cataloging-in-Publication Data

Lerner, Barron H.

The good doctor : a father, a son, and the evolution
of medical ethics / by Barron H. Lerner, MD.

pages cm

Includes bibliographical references.

ISBN 978-0-8070-3340-1 (hardcover : alk. paper)

ISBN 978-0-8070-3341-8 (ebook : alk. paper)

1. Lerner, Barron H. 2. Lerner, Phillip I., 1932-2012.
3. Physicians-Professional ethics. 4. Medical ethics.
5. Medical care-Decision making. I. Title.

R725.5.L47 2014

174.2dc23

2013048242

ALSO BY BARRON H. LERNER

Contagion and Confinement: Controlling Tuberculosis along the Skid Road

The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America

When Illness Goes Public: Celebrity Patients and How We Look at Medicine

One for the Road: Drunk Driving Since 1900

In loving memory of Cooper Dean Stock,
Phillips grandson and Barrons nephew,
August 9, 2004January 10, 2014

The senior physician, a consultant specializing in infectious diseases, was making rounds one morning in 1996. One of his patients was a woman with end-stage vascular disease and severe arthritis that left her unable to get out of bed. Even minor changes in position caused abrasions and ulcers to form on her extremely fragile skin. The patient had been hospitalized for several months with highly resistant infections and was unlikely to ever leave. On several occasions, she had remarked to the consultant that her quality of life had become unbearable.

When the doctor and his team entered the patients room, she was staring straight ahead and not moving. The physician checked for a pulse. There was none, but the womans wrist was still warm. She had just died.

One of the younger physicians ran down the hall to get the patients nurse. Hospital protocol mandated that the chest team be called and that cardiopulmonary resuscitation (CPR) be performed. Although the patients condition was dire, her primary physician had not obtained a do-not-resuscitate (DNR) order that would have prevented the CPR.

Nevertheless, the senior physician overruled this, stating that resuscitation should not be done. But when he and his team left the ward, the nursing staff decided to call the chest team anyway. Hearing this announced on the hospitals overhead paging system, the physician returned to the bedside. That is when he did something extraordinary: he placed his body over the patient, deliberately blocking his colleagues and foiling their desperate attempts to perform CPR. Despite their frantic objections, he stayed in place for several minutes, until they finally gave up. The patient was declared dead.

Individuals who have recently spent time in hospital settings know all about DNR orders and the need for terminally ill patients to make their own end-of-life choices. This doctors decisionto prevent the further treatment of a patient whose condition was terminaloccurred in a period of transition, when Americans were still learning about concepts like informed consent and advance directives. Nevertheless, what the senior physician did was highly irregular, violating both hospital protocol and the evolving ethical standards of the time.

This doctors son was also a physician, trained a generation after his father. He had been studying bioethicsthe very field that was establishing the new rules about death and dying. When his father told him the story, he was horrified. You cant do that! the shocked son cried. Of all people, he thought, how could his father, such a revered physician, so blatantly play God?

The doctor in this story is my father, Phillip I. Lerner. And I am the son.

When I was growing up, family and friends were always telling me what a wonderful doctor my father wasbrilliant, a gifted teacher, and devoted to his craft. Medicine, they said, was his calling. My dad was born into a religious Jewish family in Cleveland in 1932, and his decision to become a physician stemmed from his upbringing, although he himself was not observant. He attended a medical school that emphasized a new, humanistic approach to education. Over the years, he became a highly respected infectious disease specialist, known both nationally and internationally. During my fathers career, he often did not bill patients. He labored most evenings writing detailed scientific papers about cases he had encountered, spent his summer vacations in frequent phone contact with covering physicians, and rewrote his medical-school lectures every year, even though some of his colleagues couldnt be bothered to do so. He developed incredibly intense relationships with patients and families, intervening in lives, not just diseases. This type of doctoring was a dying art. But it contributed mightily to my own decision to become a physician.

After completing my residency in internal medicine in 1989, I was awarded a fellowship that enabled me to return to school to study history and bioethics. Eventually, I became one of a handful of MD-PhD historians who straddled the worlds of both clinical medicine and the history of medicine, seeing patients, teaching students, and writing books and articles. Much of my research into diseases like tuberculosis and breast cancer focused directly on the decisions that various physicians of my fathers generation had made. Many of the ethical precepts instituted in the bioethics movement of the 1980s and 1990s, I found, came in response to transgressions made by my dads peers in the decades after World War II.

Moreover, my father himself was one of the guilty parties. As I would learn, during his infectious diseases fellowship, he participated in experimentation on mentally disabled children without obtaining consent from the subjects or their guardians. He had a tendency to conceal information, and at times even outright lie, if he thought that such choices were in the best interests of a patient or a patients family. And, as the above story demonstrates, he became increasingly upseteven distraughtabout the use of advanced technologies to prolong the lives of dying patients, a situation that bioethicists have termed medical futility. On more than one occasion, my dad took matters into his own hands. Physicians, he believed, should simply not be allowed to offer aggressive options to terminally ill patients. This inclination to overrule patients and families violated the principle of patient autonomy, which was at the heart of the emergence of bioethics. Finally, my father saw little wrong in directing the medical care of his own sick relatives, an absolute taboo from our modern perspective. When I suggested that he and his colleagues had made many poor ethical judgments during their careers, he often disagreed.

Ten years after my father prevented his colleagues from administering CPRor, as he saw it, after he permitted a terminally ill patient to die with dignityhe had developed Parkinsons disease and was cutting back on his duties as a prelude to retirement. I often visited my parents in Cleveland, and, after each trip, I returned to New York with a stack of the journals that my father had kept, with entries dating as far back as my first birthday, in September 1961.