My Ethical Beacons: Plato, Aristotle.And Mr.Phillips
Pearson, Steven D., Medical Economics
Decisions about managed care are clear-cut-in theory. Add a trusting patient to the scenario, and they get a lot tougher.
I practice general internal medicine and teach professional ethics at Harvard Medical School. To help students learn about ethics in this era of managed care, I often refer to the thoughts of Plato, Aristotle, and Kant. But for real inspiration and insight, I rely much more on my memory of an irascible old man, Ted Phillips. Let me introduce him to you as I do to my students.
Above is a picture of him taken 10 years ago, sitting with one of his grandchildren. That's when I first met him; I was in my first month of internship, and he was flat on his back in a ridiculously small hospital gown. He'd just been admitted after passing out at a trolley stop. He'd mistakenly taken too many of his blood pressure pills. His hospitalization was short and uneventful, but in that brief time I enjoyed getting to know him. He was a proud man, a retired engineer and professor of communications. After he went home from the hospital, he switched physicians and chose me as his primary care doctor.
From the beginning I was deeply fond of Mr. Phillips, as I believe most of us are of our first patients. They give us their trust so willingly, even though they-and we-know that we are inexperienced and have so much to learn.
Over the next few years, I learned that my affection and attention couldn't prevent Mr. Phillips from having a pretty rough time, Several years after he became my patient, he was suffering the combined effects of a heart attack, new-onset atrial fibrillation, worsening joint problems, and falls. But worst of all were the unmistakable signs of slowly progressive dementia.
He deftly covered his short-term memory loss with false bravado and humor, but he couldn't hide his deep fear of recurring episodes of disorientation. He'd tell me his experiences of waking up and thinking he was at home as a boy in a small town in Illinois, actually seeing his old bedroom before him, but knowing it wasn't real.
Occasionally he'd be driving in Boston, turn a corner, and suddenly recognize everything as the Evanston of his young adulthood. He'd be forced to pull over until the sensation cleared.
Over the years, we sat and talked about his symptoms and concerns. Together we worked through the lab data and examinations, which showed there would be nothing to prevent his memory loss from worsening. Mostly we just talked about what was happening to him, how it scared him deeply and how it affected his family. Through discussing his flashbacks, he soon developed great pleasure in teaching me about life in Illinois in the early 20th century, the one topic on which he remained an expert as his memory in other areas faded.
During our years together, he also began to ask more about me and my life. One day he asked me to give him a piece of paper so he could write down the names of my children. Ever afterward, he never failed to greet me in the exam room with a question about how they were doing, asking about them by name. The fact that he could do this, given his increasing memory loss, always surprised me until one day several years later when I burst into the exam room and saw him staring intently at something in his hand. He quickly and neatly folded what I could see was that same old piece of paper, stuffed it in his shirt pocket, and reached out to shake my hand. And, with a broad smile, he asked by name how all my children were doing.
Soon afterward, quiescent prostate cancer that had been treated many years earlier became active again, and his health began to fail rapidly Shortly before he died-two years ago, at age 80-he came to see me. After we had spent most of the visit covering my agenda, he slowly reached into his back pocket and pulled out a tin can, meticulously crushed flat. …