Bernat, James L. MD, FAAN
The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics. By Barron H. Lerner. 240 Pages. Beacon Press 2014.
I wish I had known Dr. Philip Lerner. I especially wish he had taken care of my family. He was an extraordinarily dedicated physician whose life revolved around his duty to always be the best possible doctor to his patients.
In The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics, the life and career of this unique physician emerges through observations shared by his son, Dr. Barron Lerner — supplemented by stories from the extensive personal journals in which Dr. Philip Lerner chronicled a lifetime of cases and his reflections on them and on his medical practice.
The reader discovers that Dr. Lerner was uncompromising in his standards of excellent medical care, always trying to do the right thing for patients while thoughtfully and humbly questioning his own decisions. He was also willing to bear the unpleasant consequences of holding his colleagues to his own lofty standards because it was best for their patients.
The senior Dr. Lerner went to exceptional lengths to care for and protect his patients. In one remarkable story, he threw himself on top of one of his dying and suffering hospitalized patients to block the resuscitation team from performing an inappropriate and harmful CPR, which he felt he could not stop in any other way.
He believed that “doctors know best” and that he should unilaterally make medical decisions for patients, an authority that he regarded as his singular professional responsibility. He withheld medical information from patients when he felt the information would harm them.
He took care of his close family members because he judged that it was his family responsibility and that he could give them the most attentive medical care. He befriended some patients and gave them extra attention; he worried about them as he would for a close family member. He alone decided when a patient's illness or suffering burden was so great that it was time to withhold life-prolonging therapies to allow the patient to die, and he single-mindedly made sure that it happened.
It is easy to understand how much the younger Dr. Lerner admired and was proud of his father and how much his father was a model for his own development as a physician. But as Dr. Barron Lerner progressed through medical school, trained in internal medicine, obtained a PhD in history, and developed into a medical ethicist, he became increasingly aware of the gulf between the prevailing standards of professional conduct in his father's era and those in his own.
This biographical and autobiographical book spins two parallel but interwoven stories of the professional development of father and son into caring and highly ethical physicians and insightfully observes how norms of medical ethics have evolved over succeeding generations.
One area in which the prevailing standards have changed is defining professional boundaries. Today, providing medical care for close family members is discouraged (and unlawful in some places) because of the assumption that the emotional relationship of family members obscures objectivity. Although physicians continue to care for family members, usually they restrict their professional involvement to brief treatments for self-limited illnesses or emergency situations. But Dr. Philip Lerner became the actual or essential physician for his close relatives, including making their medical decisions at the end of their lives and ordering their medications and treatments. He believed that family love and loyalty required it.
Another striking difference between contemporary and past medical standards is the extent to which paternalism is justified. Dr. Philip Lerner controlled the flow of information to his patients and made their medical decisions for them. His journals suggest that he believed it was his professional responsibility to remove this burden from patients. Of course, by contemporary medical ethics standards, such paternalistic behavior would be regarded as unjustifiable and wrong. Yet, the unfettered patient autonomy currently advocated by some medical ethicists needs to be balanced by physician beneficence, particularly when patients ask physicians for advice or defer to them to make their medical decisions because of their experience and judgment.
The gap between the attitudes of the two Dr. Lerners over consent for clinical research initially seemed great. In discussions between the father and son late in the father's career, they traced the evolution of the role of voluntary informed consent as an ethical prerequisite for human subject participation in clinical research. The elder Dr. Lerner conceded that consent is a desirable action but noted that, formerly, the human subject's trust in the physician-researcher to do the right thing was relied upon rather than obtaining explicit consent. Today both trust and consent are deemed necessary ethical conditions for clinical research.
In the most moving section of the biography of his father, the younger Dr. Lerner catalogues the changes in medical practice that had swept the United States by the 1990s, upending his father's medical practice ideals, and leading to his disillusionment and frustration. Dr. Philip Lerner was especially distressed by the inexorable rise of the medical administrative insurance and regulatory bureaucracy that usurped physician authority. Foreseeing the decline in professional prerogatives that in the years to come would become even more damaging to the patient-physician relationship, he made the following entries in his journal: “My daily activities in the hospital are already swinging drastically in favor of documenting rather than doing ... I am a cog in a large, impersonal juggernaut of activity, much of it wasteful.” The final blow came when, ostensibly to comply with Joint Commission regulations, hospital administrators closed the makeshift microbiology laboratory in which he had taught a generation of residents and students to perform his beloved Gram stain technique.
In an ironic but fitting conclusion, the younger Dr. Lerner describes his father's progressive physical and intellectual decline from Parkinson's disease, culminating in its terminal phase requiring nursing home placement. At the point the senior Dr. Lerner was clearly dying, his son determined that it was time for his father to receive hospice care. In a poignant passage, he noted that his father had frequently and favorably quoted the18th century physician Thomas Fuller who wrote that the good doctor was one who “when he can keep life no longer in, he makes a fair and easy passage for it to go out.” Dr. Barron Lerner, the loving and respectful son of the magnificent physician, Dr. Philip Lerner, had learned the ultimate lesson from his father and became that good doctor.
Dr. Bernat, the Louis and Ruth Frank professor of neuroscience and professor of neurology and medicine at the Geisel School of Medicine at Dartmouth University, is a member of the editorial advisory board of Neurology Today.