The Doctor Used to Know Best

Inside a physician's 50-year-old journals, from a time when doctors made decisions for patients, not with them
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Louis Weinstein (front row, center) and his infectious diseases team, including Dr. Phillip Lerner to his immediate left, circa 1962 ( Beacon Press )

Minutes ago, she was not dead. Now she was in the space where expiration might be revoked by forcibly compressing her chest. Dr. Phillip Lerner decided that would not be right. As his colleagues rushed into the elderly woman’s hospital room to perform CPR, Lerner threw his body over hers to prevent it.

That was one of the most jarring stories Dr. Barron Lerner discovered when reading his father’s journals after the latter died. An infectious disease specialist at some of Boston and Cleveland's major academic hospitals beginning in the 1950s, Phillip Lerner kept journals for over 40 years during a time of upheaval over the omnipotent roles of doctors.

The woman in this case, a patient he cared for later in his career, had been in “agonizing” pain. She had been hospitalized for months and bed-bound for years. Though it was not formally documented, Lerner believed there was a tacit understanding between them as to when it was time to allow her to naturally die. After preventing the resuscitation, Lerner wrote that he had acted “in the name of common, ordinary humanity” based on “30-plus years as a physician responsible for caring and relieving the pain of [his] patients who can’t be cured.”

This sort of decision is at odds with the bioethics movement that began in the 1970s—the revolution in patients’ rights that Barron Lerner has championed as an ethicist and professor at New York University School of Medicine. That made reconciling some of the stories in the journals difficult as he read them. Lerner has predicated a career on rejecting outdated notions of physician paternalism, in favor of informed consent and patient autonomy. The era of doctors keeping patients and their families in the dark, making life-and-death decisions without them (or their next of kin), is what the bioethics movement sought to change. Especially following the scandal in Tuskegee, in which doctors purposely withheld penicillin from black men in order to observe the course of syphilis, being an ethical doctor came to mean not making decisions so much as empowering patients to make decisions.

Nonetheless, Lerner's journals showed how paternalism was born of a deep-seated devotion to patients. As a resident at Boston’s Beth Israel Hospital in the late 1950s, Dr. Phillip Lerner spent every other night in the hospital. As an attending physician, he regularly worked seven days a week. He knew his patients through and through, knew their families, knew their lives, and treated the patient as a whole person. It was in keeping with this mindset that most physicians in his generation believed it was their duty to make the best decisions possible for their patients. Anything less, including offering patients a menu of treatment options, was failing to fulfill a responsibility.

Lerner writes about this tension in his new book on the evolution of medical ethics, The Good Doctor. We talked about what it was like to read the journals, where the role of a doctor now stands, and where it might go. 

***

Hamblin: The book begins with this story of an elderly patient that your father prevented from being resuscitated.

Lerner: This is one of those patients that had been in the hospital for months and wasn’t getting any better and was in pain and suffering, daily. My dad basically thwarted the rules that said you have to resuscitate someone if they don’t have a Do Not Resuscitate (DNR) order. It was the height of his paternalism. And he even acknowledged that. 

My initial response was to feel pretty appalled because I was teaching bioethics at the time, and here was my own father violating one of the cardinal rules of bioethics. But part of the journey of my book was to immerse myself in his journals and understand his whole mindset about doctoring in patients, and in that context even though most people would say that what he did was illegal and unethical, I entirely understood his reasoning. It was just a completely futile resuscitation and just inappropriate, and he took it upon himself to prevent it.

You also write about the difficulty of your father treating members of your family.

This was the most disturbing thing for me. He crossed the line in a few instances where he was treating my grandmothers, got too involved in their cases, and actually tried to speed their deaths when they were quite ill. That was something that I again struggled with in the book. I understood what he was trying to do, but couldn’t forgive him in those cases.

This book is a lot about death and dying and ethics, but part of the fun about writing about my dad was discussing the great diagnoses that he and other doctors were able to make. My dad had trained in the 1950s and ’60s. His mentor was a guy named Louis Weinstein, one of the founding fathers of infectious diseases. Weinstein was from the era where he saw all these people with infections die, basically, and saw these atypical infections that people didn’t see anymore and he imparted this knowledge to my dad.

Barron and Phillip Lerner

So my father was one of the last generations of these diagnosticians who had seen all of these atypical infections and could go on rounds when all the other doctors were scratching their heads, befuddled, and say, Aha! I saw that 30 years ago when I was training, and I know what this is. Not only do these events make for good stories because it’s sort of a detective game, but it also gave my father the legitimacy and credibility that he carried with him during his years as a doctor. In an era before CT scans and MRIs, he could not only make these diagnoses so skillfully, but then tie his medical diagnosis to his medical care for the patient and his intense interest in their lives.

Before CT scans and the like, when diagnosis and treatment was more based only on physical examination, asking questions, and intuition, that also may have informed this paternalism where the doctor just knew what was going on and what was best for the patient. That was the culture. Now we’re all about objective measures—you can show the CT scan to a patient and their family, show them where there's  hemorrhage and why we should operate or shouldn't operate, for example, but before you had to trust the doctor.

In some ways the difference is epistemological; there was a different way of knowing then. Look, knowing what we know now from these tests is spectacular. Who wants to speculate? But there was a connection between knowing, just having so much clinical experience and having seen so many patients with so many complicated issues, just knowing what these diseases were like and how they were likely to progress gave my dad incredible credibility and wisdom. I guess I’m trying to get back a little of the old kind of knowing in our modern era of technology, where we also know a lot, but know it in a different way.

Some of these practices might feel clearly archaic to readers, but it really wasn’t long ago. Is the controlling doctor a relic, or should expertise sometimes still overrule patients and their families? Is it possible to know what’s best for another person?

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James Hamblin, MD, is a senior editor at The AtlanticHe is the host of If Our Bodies Could Talk.

 
 
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