Fathers and sons have always had power struggles. This one is worth reading about because it speaks to ethical issues on a societal level that ASCO Post readers will appreciate.
Title: The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics
Author: Barron H. Lerner, MD
Publisher: Beacon Press
Publication date: May 13, 2014
Price: $25.95; hardcover, 240 pages
One morning in 1996, an infectious disease specialist was making rounds when he and his team entered the room of a patient with end-stage vascular disease and severe arthritis that had left her bedridden. She was staring straight at the ceiling and not moving. The physician checked for pulse and found none; the woman’s wrist was still warm, she had just died.
Hospital protocol mandated that the chest team perform cardiopulmonary resuscitation. Although the patient had been in dire condition for several months, her primary care doctor had never obtained a do-not-resuscitate order. Despite hospital protocol, the senior physician overruled the CPR mandate, and when the chest team arrived to perform the procedure, he did something remarkable—he placed his body over the patient and held his position until the patient was officially declared dead.
Over the next few years, this same doctor attempted to hasten the deaths of his critically ill mother and mother-in-law, to spare them continued suffering. Moreover, during his infectious disease fellowship, this doctor participated in experimentation on mentally disabled children without obtaining consent from their parents. The doctor’s name was Philip I. Lerner, MD, and his son, Barron H. Lerner, MD, has just published a book, his fourth, titled The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics, which examines the issues surrounding life and death and illness, and a doctor’s ethical role in the various stages of that human drama.
Dr. Lerner—who is a bioethicist, medical historian, and internist at New York University’s Langone School of Medicine—uses his father’s medical career and illness during his elder years to frame this book’s compelling storyline. He introduces his father in chapter 1, “The First Dr. Lerner. He gives the reader salient points and lessons learned that shaped his father’s passion and, at times, overly zealous approach to doctoring.
His father was an American Jew of Ashkenazi decent who was reared in a close-knit working-class Jewish neighborhood during World War II. “Although he was largely unaware of the mass murder of Jews as it was occurring, what he learned later would affect many aspects of his medical world. His career trajectory was also influenced by his attending a medical school that was in the forefront of efforts to train humanistic physicians,” writes Dr. Lerner. Early on, he alludes to his father’s dubious view of a medical ethos that too often bent on prolonging life at any cost.
The book gathers steam when Dr. Lerner decides to follow in his father’s medical footsteps. Although there is much interesting content about balancing a medical life with home and family, the core of this book’s narrative is based on the age-old ethical question of medical paternalism and the doctor acting as a demigod in health-related decisions. The clash between father and son on ethical issues is what brings the narrative to a boil. Dr. Lerner deftly depicts a time when the lay public first challenged the ivory tower of medicine. To that end, readers of The ASCO Post will delight in Dr. Lerner’s discussion of the early health activists, particularly in breast cancer. He describes a time when surgeons did biopsies of breast lumps while women were under general anesthesia, and if the biopsy were positive, the surgeon would perform radical mastectomy, forging ahead without awakening the woman. Women would routinely awaken from anesthesia and reach to feel whether their breast had been removed.
Concise and Colorful
In the early 1970s, with the support of the iconoclastic surgeon, George Crile, Jr, MD, and a group of activist women—best known among them, Rose Kushner—this reflexive use of mutilating surgery was publically challenged. “Neither a breast surgeon nor a gynecologist, my father was less likely to encounter these activist patients. But issues of patients’ rights were slowly creeping into his world, and at times, his notes contained a glimmer of the coming revolution,” writes Dr. Lerner. His concise and colorful telling of medical history is one of this book’s strongest features.
Dr. Lerner delves into how physicians deal with sickness among loved ones in a short chapter called “Illness at Home,” during which he writes with a sort of detached passion about his mother’s breast cancer diagnosis, mastectomy, and subsequent chemotherapy regimens. He captures the epoch of silence surrounding cancer, especially breast cancer.
“My memories of this time are that things around the house were hush-hush. My parents surely told our close relatives and friends, but my sister and I were probably instructed to tell people who asked only that my mother was sick,” writes Dr. Lerner, recalling sadly that his mother spent “a huge amount of time by herself in her bedroom.” He also comments on the early days of chemotherapy, when doctors had a more-is-better attitude and lacked the supportive care tools of today. “I remember a lot of retching and vomiting coming from behind her closed door.”
As Dr. Lerner tells of his own entrance and journey into a medical career, the reader feels the presence of his father looming over his son’s story. The emotional intersection of these father-and-son doctors is both illuminating and claustrophobic.
In a line that succinctly describes their tension, Dr. Lerner writes, “one issue as to which my father was clearly right, twenty years ahead of most others: his objection to percutaneous endoscopic gastronomy tubes to feed patients with end-stage conditions who could no longer eat.” Only one issue, the reader might ask?
Dr. Lerner’s father was in his 50s when the AIDS pandemic surfaced. His father kept meticulous diaries and journals detailing his cases, and much of the book’s more intriguing sections are devoted to Dr. Lerner’s examinations of these voluminous notes. “As my father approached his late fifties, he encountered perhaps the most challenging patients of his career…. [W]hen I opened one of his journals, a photograph of one of his AIDS patients, a gift from the man’s parents after their son died, fell out.”
But for all the heartfelt admiration Dr. Lerner shows for his father, there is the constant struggle to understand him that gives the book its dramatic tension. In his journal, the senior Dr. Lerner wrote, “I find that I am literally in the position of determining when and how a patient will die.” This one sentence drills to the heart of the father-and-son conflict, one that speaks to the most pressing issues of our day, in an era of high-tech medicine and out-of-control health-care costs.
Personal and Professional Questions
As Dr. Lerner’s father slowly died of Parkinson’s disease, his son faced these questions both on the personal and professional side. Drawn into his father’s care, he was confronted with the same medical decisions that he had criticized his father for. He had to ask himself, did doctors sometimes know best and did playing God—at least in some situations—offer better and more compassionate care?
Fathers and sons have always had power struggles. This one is worth reading about because it speaks to ethical issues on a societal level that ASCO Post readers will appreciate. Without trying too hard, it also points out that doctors are flesh-and-blood people, just like the sick people they care for. ■