Can Osler teach us about 21st-century medical ethics?

In medicine, we are voyeurs. We are present at the most intimate and personal of our patients' experiences. We are there at birth; we pronounce their passing; we listen to the tales of humanity, of griefs and triumphs, of what takes place behind closed doors. We are trusted, we are confided in, we have become very much as secular confessors and can listen, if we choose to take the time, to the nuts and bolts that make each one of us unique, as a story spills out over a series of encounters. But while our white coats lend an aura of priestly authority, our texts are imperfect and require revision every 5 years or else are out of date; we cannot quote with authority as one might from the Old Testament, or Koran, or the Bhagavad Gita. Medical truth appears almost evanescent and transient, a linguistic oxymoron, much unlike the Forms that flickered on the walls of Plato's cave. Our patients turn to us for wisdom, for counsel, for help, for cure and restoration of health in the setting of disease. Sometimes, the questions are easy: frankly metastatic cancer, unknown primary, is easy to treat, or perhaps more accurately easy not to treat. Straightforward extrinsic asthma likewise is usually a “slam dunk.” But other questions nag at our consciences because we might not really know the right answer, and our patients get very uncomfortable when we admit our human frailty and the imperfection of our knowledge. And then our feelings and our loyalty to colleagues and to political, religious, or ethical beliefs may influence our opinions on topics that we never discussed in medical school or learned about in residency or fellowship training. Understanding the facts of a case, and searching for an answer, either with UpToDate or Hippocrates or just Googling for help, often helps to answer medical issues of a content nature: a diagnosis, a treatment, a prognosis. But the dilemmas of life are not often so content driven. When I speak with my colleagues and friends of the struggles they face, it isn't about treating coronary artery disease or diabetes. When I polled for the real issues that seemed to defy the latest edition of Harrison's textbook, these were at the top of the list: When family members aren't on the same page as the treating team in the setting of irreversible illness When a mistake is made and the patient is unaware When consultants disagree over treatment and lobby the patient to accept their own version of the truth When insurance changes limit access and continuity of care, or denial of service can only be avoided through a convoluted documentation process that takes more time to master without recompense than the service itself Medscape, the Internet health care professional section of WebMD, published a survey of physicians about the most common ethical dilemmas (1). This survey listed additional items physicians struggle with: Reporting an incompetent or impaired colleague Owning up after making a medical error Physician-patient confidentiality when one partner of a couple is HIV positive and the other doesn't know Prolonging futile care for a dying patient Denying care to a nonpaying patient Whether to honor a family's request not to tell a patient that he or she has a terminal disease Exaggerating a patient's condition to get insurance coverage Writing a prescription for a family member or friend Ethical principles allow us to derive moral instructions to address specific dilemmas we face, and a useful construct to evaluate controversial issues is that of Beauchamp and Childress (2), who created a hierarchy of four principles: Patient autonomy, the right to refuse treatment Beneficence, the adjuration to “do good” Nonmaleficence, the instruction to “do no harm” Justice, both “doing the right thing” and ensuring “distributive” fairness This hierarchy, which is often employed by ethics consultants in the hospital addressing the specifics of any circumstance, reflects contemporary emphasis upon the individual's freedom to refuse treatment options–—which is not to be confused with the right to demand specific treatments that might be untherapeutic or potentially harmful. Autonomy may also be construed as the right to “know,” because appropriate decision-making or more classically “informed consent” requires the full disclosure of risks and benefits. This rank order of ethical principles differs from that in previous eras, when a paternalistic beneficence trumped all other values. Reordering such adjurations may lead to significant differences in any particular decision in the setting of a moral dilemma, and that fact must be considered when we look back into our heritage for answers to our current problems. Solomon may have written that “there is nothing new under the sun,” but the reflection of light upon the landscape of choices varies with the era and time as much as anything else. In truth, the very concept of “good” can become redefined based on changes in societal values. For example, at various times in history, the goodness of racial purity was held paramount, which led to 20th-century atrocities against European Jews at the hands of fair-skinned, blue-eyed Germans and the segregation of races in the USA following the Emancipation Proclamation. History can inform us, then, of a traditional perspective against which we can compare our current views, for better or for worse. In fact, the majority of our current dilemmas are but reflections through the darkened glass of time of previous struggled-with issues that are now reprised in our own time. As such, it is instructive to look backwards at those who were clear masters in their own days and articulated choices and a perspective that history judges as authentic. Such a master was William Osler (Figure ​(Figure11). Figure 1 Sir William Osler. From Images from the History of Medicine, National Library of Medicine.