William Osler’s medical ethics in the 21st century
Richard L Golden
Mark W Millard. Can Osler teach us about 21st century medical ethics? Baylor University Medical Centre Proceedings. 2011; 24(3) 227-35.
The ineluctable allure and wisdom of Sir William Osler, which now spans three centuries, is elegantly put to the test by Mark Millard in determining its applicability to the medical ethics of the 21st century. While there is little doubt that our current technical knowledge and capabilities will be regarded as primitive by the end of the century, if not well before its midpoint, how will our current ethical standards be viewed? Are the teachings of William Osler, the preeminent physician of his time, applicable to modern ethical dilemmas?
The author raises the issues of treatment of irreversible illness; medical error and patient awareness; disagreement among consultants; and third-party payers limiting access, continuity of care, or denial of service. He further cites a survey of physicians that selected as major problems those of the incompetent or impaired colleague; confession of medical error; physician-patient confidentiality in couples when one partner is HIV positive; the prolongation of futile care in a terminal patient; denial of care to those who cannot pay; whether to honour a family’s request not to tell a patient that he/she has a terminal disease; exaggerating a patient’s condition to obtain insurance coverage; and writing prescriptions for friends or family members.
A hierarchy of ethical principles is cited that offers guidance: patient autonomy (the right to refuse treatment); beneficence (the adjuration to “do good”); non-maleficence (the instruction to “do no harm”); and justice (both “doing the right thing” and ensuring “distributive” fairness); ethical principles that include the right to know and informed consent, differing from the paternalistic beneficence of earlier times. The caveat is given that the rank, order, and definition of these ethical principles are subject to temporal interpretation and may change from one era to another. Examples are cited of Osler’s teachings and personal approach to some of these problems, including euthanasia and assisted suicide, and the economics of medical practice.
William Osler (1849-1919), the foremost physician of the English-speaking world, was born in Bond Head (Ontario), Canada, one of the nine children of an Anglican clergyman. After graduating MD from McGill University (Montreal) he spent the usual wanderjahre in Europe, honing his skills in medicine and pathology in the laboratories and clinics of London, Berlin, and Vienna. Returning to McGill he quickly rose to become Professor of the Institutes of Medicine and with an ever growing reputation went on to successive professorships at the medical faculties of the University of Pennsylvania (Philadelphia), Johns Hopkins University (Baltimore) where he served as the first Physician-in-Chief of the Johns Hopkins Hospital, and capped his career as Regius Professor of Medicine at Oxford University; an unprecedented journey spanning two continents and three nations. It was at Johns Hopkins that he published his renowned single-authored textbook, The Principles and Practice of Medicine, that went through 16 editions (1892-1947) encompassing over 500,000 copies and influencing successive generations of students and practitioners. Its influence was not limited to the English-speaking world which saw American, British, Australian and Indian (Calcutta) editions, but had a global impact as a result of translations into Russian, French, German, Chinese, Spanish and Portuguese (1).
Osler had over 1,600 publications including books, articles and essays on medical, philosophical, historical, educational and biographical topics. His enduring influence rests on a legacy of clinical, scientific, literary, educational and intra-professional achievements, linked to the lodestone of a remarkable personality, and bound together by ethical principles and an extraordinary humanism.
In considering William Osler’s medical ethics, we must acknowledge that in many ways he was a man of his Victorian-Edwardian times, but tempered by his historical and philosophical studies and an innate humanism that left him far ahead of his time and remarkably free of prejudice. His cousin, Norman Gwyn, commented that “the seed of prejudice must have fallen on stony ground in Sir William’s case… ” (2). Osler declared:
What I inveigh against is a cursed spirit of intolerance, conceived in distrust and bred in ignorance, that make the mental attitude antagonistic, even bitterly antagonistic, to everything foreign, that subordinates everywhere the race to the nation, forgetting the higher claims of human brotherhood (3).
In a more pithy statement he proclaimed: “The great republic of medicine knows, and has known no national boundaries.” This is the heartening theme of today’s altruistic Doctors Without Borders (4).
Humanism in its broad sense was not part of the idiom of Osler’s time, although its concept was well known. It is a word that is often glibly used and difficult to define. Osler was once questioned as to why he merrily whistled after leaving the bedside of a gravely ill patient. He revealed the depths of his humanistic empathy in responding: “I whistle that I may not weep.” (5) Another poignant example occurred during Osler’s Oxford tenure when he was called to the home of a colleague to see a child “with very severe whooping cough and bronchitis, unable to eat and wholly unresponsive to the blandishments of parents and devoted nurses alike. Clinically it was not an abstruse case, but weapons were few, and recovery seemed unlikely.” Osler, on his way to graduation ceremonies in his academic robes, stopped and saw the child and after a brief examination peeled, cut, and sugared a peach which he fed bit by bit to the enthralled patient. Although he felt recovery was unlikely, he returned every day for the next 40 days, each time dressed in his robes, and personally fed the small patient some nourishment. In a short time the tide began to turn and recovery became evident (6). This is humanism that is readily understood on a visceral level.
Osler’s medical ethics derived in part from his upbringing as the son of a clergyman, his early mentors, his philosophical and historical studies, and his fascination with the concepts and principles of the ancient Greeks from whom he embraced the Hippocratic “philanthropia and philotechnia”-“the love of humanity coupled with the love of his craft.” (7) Osler particularly adopted the lessons and standards of the Hippocratic Oath and its ethical obligations. While the spirit of the Oath remains intact, a newer Declaration of Geneva now embraces some more modern concepts. He often quoted from Poe of “the glory that was Greece, and the grandeur that was Rome.” (8)
Among Osler’s aphorisms and postulates he inveighed:
You are in the profession as a calling, not as a business; as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow man. (9)
Distinctions of race, nationality, colour, and creed are unknown within the portals of the temple of Aesculapius. (10)
No one should approach the temple of science with the soul of a moneychanger. (attributed to Sir Thomas Browne) (11)
Care more particularly for the individual patient than for the special features of the disease. (12)
At a farewell dinner in New York in 1905, before leaving to assume the Regius Professorship in Oxford, he candidly discussed his ethics (13) (quoting Matthew Arnold) confessing:
I have made mistakes, but they have been mistakes of the head not of the heart. I can truly say, and I take upon myself to witness, that in my sojourn among you:
“I have loved no darkness, Sophisticated no truth, Nursed no delusion, Allow’d no fear!” (14)
There is no doubt that, in general, Sir William Osler’s ethical standards and approach to the practice of medicine remain pertinent and fresh. In a world where doctors have become “providers” and patients “consumers”; where “cost containment” and third party payers limit choices; where access to medical care is limited or non-existent, and life-saving drugs marketed at egregiously high cost, the example of Osler and “virtue ethics” are a beacon in an evolving, and frequently, disturbing practice of medicine.
Listen to Osler’s own words:
I have three personal ideals. One, to do the day’s work well and not to bother about to-morrow… The second ideal has been to act the Golden Rule, as far as in me lay, towards my professional brethren and towards the patients committed to my care. And the third has been to culture such a measure of equanimity as to enable me to bear success with humility, the affections of my friends without pride and to be ready when the day of sorrow and grief came to meet it with the courage befitting a man. (13)
For those who wish to learn more of William Osler and his ethics than can be offered in this brief review, read Dr Millard’s insightful article and then, if the spark successfully ignites the kindling of intellectual curiosity, proceed to the delightful biographies of Michael Bliss (15) and Harvey Cushing (16).
- Golden RL. A History of William Osler’s The Principles and Practice of Medicine. Montreal: Osler Library, McGill University and the American Osler Society; 2004.
- Gwyn NB. The boyhood of Sir William Osler. CMAJ. 920:10:24-7.
- Osler W. Chauvinism in medicine. In: Aequanimitas with other addresses to medical students, nurses and practitioners of medicine. Philadelphia, Pa: P Blakiston’s Son and Co; 1906: 277-306.
- Osler W. The importance of post-graduate study. Lancet. 1900; ii:73-5.
- Osborne M. Recollections of Sir William Osler.Int. Assoc. Med. Mus. Bull. 1926; 9: 171-4.
- Mallam P. Billy O. JAMA.1969;210:2236-39.
- Osler W. The old humanities and the new science.Boston and New York: Houghton Mifflin & Co;1920:63-4.
- Poe, EA. To Helen (1846 revision). In: The Raven and Other Favorite Poems. Mineola, NY: Dover Publications;1994:12.
- Osler W. The reserves of life. St. Mary’s Hosp Gazette.1907;13:96-8.
- Osler W. British medicine in Greater Britain. In: Aequanimitas with other addresses to medical students, nurses and practitioners of medicine. Philadelphia, Pa: P Blakiston’s Son and Co;1904:167-96.
- Osler W. Valedictory address to the graduates in medicine and surgery, McGill University. Can Med Surg J. 874-1875;31:433-42.
- Osler W. Address to the students of the Albany Medical College. Albany Med Ann. 1899;20:307-9.
- Osler W. L’Envoi. In: Aequanimitas with other addresses to medical students, nurses and practitioners of medicine. Philadelphia, Pa: P Blakiston’s Son & Co;1906:467-74.
- Arnold M. Empedocles on Etna. In: The poems of Matthew Arnold, 1840-1867. London: Henry Frowde, Oxford University Press; 1909:124. (Act II, Lines 400-403).
- Bliss M. William Osler: A Life in medicine. New York: Oxford University Press; 1999.
- Cushing H. The life of Sir William Osler. Oxford: Clarendon Press;1925.