This feature is part of a year-long series of excerpts and special commentaries celebrating AFP's 50^th year of publication. Excerpts from the two 1950 volumes of GP, AFP's predecessor, appear along with highlights of 50 years of family medicine.

This feature contains excerpts from the article “Ethics in Medicine,” by Walter C. Alvarez, M.D., published in the September 1950 issue of GP , and commentary by Caroline Wellbery, M.D., deputy editor of AFP.

An intern working in the Massachusetts General Hospital in December of 1947 asked his Chief, Dr. J. Howard Means, some questions as to the rightness or wrongness of certain decisions that he had to make. For instance, a patient with a fatal disease could be kept alive for a while with the help of repeated transfusions, but she was using up the available stock of a special type of rare Rh-negative blood which the blood bank people thought should be reserved for the helping of persons who could be cured. Should the woman, then, be denied the blood and allowed to die?

Since Doctor Means did not feel that he could answer these questions with assurance, he asked Dean Willard L. Sperry of the Harvard Divinity School to come over and give a talk. Later Doctor Sperry gave a similar talk at the University of Michigan, and now these addresses have been expanded into a beautiful and most thought-producing book [Sperry WL. The ethical basis of medical practice. Hoeber, N.Y.: 1950]. Dean Sperry is well prepared to think and write about the ethical problems that arise in medicine because he started out to be a physician and then, after the shock of losing a dear friend, went into the ministry.

As Sperry said to the interns, he could not answer categorically all their questions. A man starts in life with the idea that right and wrong are like white and black—easily distinguishable—but as he grows older he finds that often his choice must be between two shades of gray.

Another problem that assails a physician many times a year is, “Should I labor hard to keep alive some person who not only is useless but who, if he lives on, will wreck the finances or the life of some relative who is useful?” One thinks of the aged parent with a stroke who, for years, has been abusing and impoverishing his hard-working little daughter and wrecking her life, or one thinks of the idiot child who has been wrecking the life of the mother and causing her husband to almost desert her. One thinks, also, of the man dying from cancer who, in the last six months of his life, has been made to spend on useless treatments and operations all the money he had hoped to leave for the education of a son.

The writer remembers a consultation on the case of a moron suffering from chronic ulcerative colitis. The eminent surgeon who had been asked to perform ileostomy refused to operate because he thought it much better for the boy and society that nature be left to take her course. As the surgeon said, “If I save him, what will you have left on your hands?” Doubtless, thousands of good people would have had the horrors over the “cruelty of this decision,” but would any of them have come forward and offered to pay the boy's bills for the next ten years?

Dean Sperry has two chapters on the problems of euthanasia. Like most kindly people, he fears and dislikes the thought of it, and to support his stand he is inclined to point to those rare cases in which a patient, seriously ill and hopeless, eventually recovered and became a useful citizen again. This would seem a weak argument because we physicians know that euthanasia is most commonly desired by emaciated persons, who for weeks, with a perfectly clear brain have been dying of metastatic cancer. We know how very seldom such a person ever recovers. Idiots, who often need euthanasia, of course never recover.

So many of the persons who now oppose euthanasia do not realize that the first law to be passed, when it is passed, will probably only permit a man when exhausted with hellish pain to ask for and get an overdose of morphine. There need be no fear, then, that a man will be done away with by his family or some enemy.

As Doctor Sperry admits in his book, when his old dog, blind and weak, was dying of cancer, he let the veterinary put him out of his misery. What is curious is that many a fine able man who has such compassion for a sick dog or a horse with a broken leg, will not have it for a dying father or mother or wife, but will insist that the invalid suffer on for months with perhaps the horrible torture of cancer eating into many of the big nerves of the body.

The ministers who now so oppose euthanasia might no longer do so if they had to spend a few years in a county hospital among men and women dying slowly of neglected cancer of the bladder and rectum, amid the foul stench of reeking fistulas, constantly leaking feces and urine into the bed, or with strangling cancers of the tongue or the esophagus. If the ministers could take care of such persons for a few months without wishing that they could put them painlessly out of their misery, they would be heartless indeed.

As Dean Inge, of England, once marvelled, we jail a man for failing to put his sick horse or dog out of its misery, but we always try to hang the man who does away with his idiot child, even when he does this from fear that he himself is soon to die and thus to leave the child uncared for!

The next to the last chapter in Dean Sperry's book is on “Reverence for Life.” His argument is beautiful, but if he were a physician he might add that no sensible man can feel much reverence for life when the living person happens to be an idiot or a filthy, naked, insane man, voiding his excreta on his mattress, and cursing and spitting at anyone who comes near him. When the brain is largely destroyed and gone there is not much left of a man.

Dean Sperry has written a fine, thought-provoking, scholarly, and kindly book which every physician should read. Physicians will be grateful to him for having written it, and they will be glad that a fine minister has now come forward to help them with their moral problems. Perhaps before Dean Sperry writes a second edition he will have long chats with dozens of thoughtful physicians who will tell him about more of their ethical problems, and will get his help in grappling with them. With this experience he can write an even better book. Perhaps, then, he can come out with more definite answers to some of the quandaries that now perplex us physicians.—walter c. alvarez, m.d.

Commentary

What strikes us in Dr. Walter Alvarez' review of Willard Sperry's book, The Ethical Basis of Medical Practice, is its familiarity and the distance we've travelled in the past 50 years.

Starting with the element of the familiar, we recognize that ethical dilemmas in medicine are not new. In terms of their content, the ones mentioned in this review remarkably resemble the issues we still grapple with today: the allocation of resources, futility, euthanasia.¹ We also sympathize with the author's observation that there is a gap separating the physician from his ethicist colleagues: the principles of beneficence, nonmalevolence, autonomy and justice we hear so much about today often seem abstract in the trenches, where the practicing physician may feel overwhelmed by the spectacle of suffering, conflicting demands and prognostic uncertainty.

At the same time, the writer's language alienates us with its paternalism. Full of judgment about the value of human life, the author bandies about words like “moron,” “idiot” and “useless.” We see how much influence the notion of patient autonomy has exerted in the past few years. At the same time, resolving ethical dilemmas has become more difficult for us in some ways. Although most of us don't hanker to condescend like the previous generation of physician, we also realize that we spend more of our time dancing around on our tiptoes trying not to offend anyone—or fearing a lawsuit.

Not only has the vocabulary of physicians become more neutral over the past 50 years, but the ethicist, too, has changed his tone. Gone are the days of describing “black and white morality” as a state of youth giving way to wisdom's grayer shades, or the “beautiful” meditations on the “reverence for life.” Bioethics has girded up its vocabulary to mimic the authoritative, scientific language of our times. Here, in the field of ethics, self-preservation has necessitated far-reaching adjustments to keep up with changed mores and fashions.² Perhaps the most promising recent development in the ethical field is the notion of clinical bioethics, as a means of responding to the empiric experiences of real-world physicians. The author of this review demanded 50 years ago that ethicists listen to what physicians are saying, and clinical bioethics may at last provide the dialogic basis he wanted.—caroline wellbery, m.d.