The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics - Softcover

Lerner, Barron H.

 
9780807035047: The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics
Softcover
ISBN 10: 0807035041 ISBN 13: 9780807035047
Verlag: Beacon Press, 2015

Inhaltsangabe

The story of two doctors, a father and son, who practiced in very different times and the evolution of the ethics that profoundly influence health care
 
As a practicing physician and longtime member of his hospital’s ethics committee, Dr. Barron Lerner thought he had heard it all. But in the mid-1990s, his father, an infectious diseases physician, told him a stunning story: he had physically placed his body over an end-stage patient who had stopped breathing, preventing his colleagues from performing cardiopulmonary resuscitation, even though CPR was the ethically and legally accepted thing to do. Over the next few years, the senior Dr. Lerner tried to speed the deaths of his seriously ill mother and mother-in-law to spare them further suffering.
  
These stories angered and alarmed the younger Dr. Lerner—an internist, historian of medicine, and bioethicist—who had rejected physician-based paternalism in favor of informed consent and patient autonomy. The Good Doctor is a fascinating and moving account of how Dr. Lerner came to terms with two very different images of his father: a revered clinician, teacher, and researcher who always put his patients first, but also a physician willing to “play God,” opposing the very revolution in patients' rights that his son was studying and teaching to his own medical students.

But the elder Dr. Lerner’s journals, which he had kept for decades, showed the son how the father’s outdated paternalism had grown out of a fierce devotion to patient-centered medicine, which was rapidly disappearing. And they raised questions: Are paternalistic doctors just relics, or should their expertise be used to overrule patients and families that make ill-advised choices? Does the growing use of personalized medicine—in which specific interventions may be best for specific patients—change the calculus between autonomy and paternalism? And how can we best use technologies that were invented to save lives but now too often prolong death? In an era of high-technology medicine, spiraling costs, and health-care reform, these questions could not be more relevant.
      
As his father slowly died of Parkinson’s disease, Barron Lerner faced these questions both personally and professionally. He found himself being pulled into his dad’s medical care, even though he had criticized his father for making medical decisions for his relatives. Did playing God—at least in some situations—actually make sense? Did doctors sometimes “know best”?
 
A timely and compelling story of one family’s engagement with medicine over the last half century, The Good Doctor is an important book for those who treat illness—and those who struggle to overcome it.

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Über die Autorin bzw. den Autor

Barron Lerner is the author of four previous books on medicine and a frequent contributor to the New York Times’ Well column, TheAtlantic.com, Huffington Post, and several blogs. He lives in Westchester County, New York, and is a bioethicist, historian of medicine, and internist at New York University’s Langone School of Medicine.

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Chapter Two
Super Doctor
 
I have written several books on the history of medicine, and I readily admit to having had unrealistic expectations about how many copies of each would be bought. Tuberculosis, breast  cancer, and even celebrity patients were less compelling topics than I had anticipated. Still, I had to chuckle when I read of my father’s onetime plan to publish a book entitled Consultant, detailing his experiences seeing patients with infectious diseases at the Veterans Administration
Hospital, Mount Sinai Hospital, and other Cleveland medical institutions in the 1960s and 1970s. As my agent could have told him, the subject was too “specialized.”
 
Fortunately, however, my father saved his notes, which not only illuminate his early medical career but also provide a moving depiction of him at the height of his powers, as he was practicing an intense type of medicine that might best be described as all-consuming. My dad provided a crucial service to internists, surgeons, and other physicians by diagnosing the illnesses of their sick patients and then prescribing effective antibiotics. His overarching concern for the physician-patient relationship also shone through in many of the cases that he documented.
 
As an infectious diseases consultant, my father turned out to have a front-row seat to some of the emerging ethical issues—such as medical errors and the limits of medical technology—that would soon burst forth into the public spotlight. But his approach to these issues remained largely based on paternalism and beneficence: How could and should the doctor help his patient navigate these complicated and often controversial questions? Given his background and training, which stressed “Doctor knows best,” he could hardly have chosen a different approach.
 
Meanwhile, I was a fairly typical teenager, trying to balance schoolwork, friends, and jobs. Two important decisions I made during these years were to have a bar mitzvah and to work for two summers at a nursing home at which my father was the medical director. The first represented an important exploration of my Judaism, although, like my father, I had great ambivalence about religion. The second turned out to be a dry run for my becoming a doctor.
 
Not all cases of infection require an infectious diseases consultation. Garden-variety pneumonias and urinary tract infections, for example, can be treated with a standard assortment of antibiotics. The task becomes even easier if a culture of the infectious material—such as sputum, urine, or blood—grows a specific organism. The microbiology laboratory can then test specific drugs against the bacteria in question, simplifying the choice of medication.
 
So when my dad was called in on a case, it was a good bet that it was complicated, either because the source of infection could not be determined or because the choice of antibiotic was unclear. For the most part, my father was happy with this arrangement. Like most physicians, he loved difficult and unusual cases, as they made for interesting discussions in the hospital corridors, on rounds, and at the citywide infectious diseases conferences he inaugurated in Cleveland in the late 1960s. Plus, even though my dad was incredibly busy, being a consultant provided him with considerably more flexibility and independence than his colleagues had, with their regular office hours and hundreds, perhaps thousands, of patients.
 
A typical case that my father saw in the early 1970s was a man with a lymphoma and an unusual pneumonia whose doctors were deciding whether or not to do a lung biopsy, which would involve opening the man’s chest. Deducing that the man had pneumocystis pneumonia, which occurred in immunosuppressed patients and would later become a common malady of the AIDS era, he convinced the team to skip the biopsy and treat the patient empirically with antibiotics. The man recovered completely.
So did a teenager with congenital heart disease who had endocarditis. Despite being treated with penicillin, he was still running temperatures as high as 105. The patient’s cardiologist was worried because the infection was not getting better, and he consulted a surgeon about replacing the infected heart valve—a major operation that the boy might not have survived. Noting that, despite his high temperature, the patient appeared to be improving, my father implored the physicians to hold off on surgery. He added another antimicrobial agent to treat what he thought was a small pneumonia. The patient never required surgery and was cured of both infections.
 
A man with pancreatic cancer had recurrent bacterial blood infections. He had recently become infected with a highly resistant strain of an organism called Serratia. The team was at a loss as to what to do to save the man’s life. My father reached into his bag of tricks and suggested trying an older antibiotic, tetracycline, not normally used for this type of blood infection. The patient recovered, although he ultimately died from the cancer.
 
When an eighty-five-year-old man was admitted to the hospital with a severe infection of his neck, my father was able to diagnose a condition that was very rare: Ludwig’s phlegmon. The infection, which had first been described by German physician Wilhelm Frederick von Ludwig in 1836, had become uncommon in the antimicrobial era but was still featured in infectious diseases textbooks. The infection required drainage of the abscess in the operating room, and my dad scrubbed in for the procedure. The surgeon had so little experience with such cases that he took my father’s recommendation that he do an extra-long “guillotine incision” of the neck to help treat the patient.
 
My dad’s consult notes, which reflected his intimate knowledge of the diseases in question, were often tutorials for the doctors (and patients) involved. When an elderly man with advanced lung disease continued to have fevers and positive sputum cultures, my father wrote: “In patients with chronic restrictive pulmonary disease, who have trouble raising secretions, antibiotic therapy of an acute pulmonary infection leads to bacterial overgrowth of the respiratory secretions.” The treatment: stop antibiotics and pound on the man’s back four times daily to mobilize his phlegm. It worked.
 
As in this case, my father’s successes often resulted from using fewer as opposed to more antibiotics, an approach he had learned early on from Louis Weinstein and one that he would impart to generations of Case Western Reserve medical students, house officers and fellows. One woman with multiple myeloma, who had been admitted repeatedly for infections, had a pneumonia that would not respond to any treatment. Given her overall condition, my dad, thinking it was cruel “to put her through any more torture,” recommended that antibiotics be withdrawn and the patient made comfortable. The pneumonia, or whatever the lung condition was, resolved.
 
In another case, a woman had severe diarrhea probably related to previous use of an antimicrobial. A visiting professor had seen the patient and recommended “massive antibiotic therapy” to clear out what he thought was an infection in the intestines. But my father had noticed that in addition to the diarrhea, there was mucus in the stool, indicating that the patient’s immune system was already fighting the diarrhea. He recommended stopping all antibiotics and simply giving her sugar water, “the way one would treat an infantile diarrhea.” The patient recovered over the next several days.
 
Finally, my father consulted on a...

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Verlag
Beacon Press
Erscheinungsdatum
2015
Sprache
Englisch
ISBN 10 
0807035041
ISBN 13 
9780807035047
Einband
Taschenbuch
Anzahl der Seiten
240
Kontakt zum Hersteller
Nicht verfügbar
Verantwortliche Person
preigu
mail@preigu.de

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