Early adventures in biomedical ethics

Late in 1949, near the end of our sixth and final year as medical students, our class had two lectures on medical ethics.  That was the title, but the content of the lectures covered both more and less. More, in that the lecturer spoke also about medical etiquette – caring for other doctors and their families without charging a fee; and an ancient tradition, teaching our art and craft to the sons of our colleagues (daughters weren’t mentioned); and medico-legal matters – how to fill in official forms like death and birth certificates.  But we were taught much less than we would need on real ethical problems. All we got was a few highlights: we must keep secret the things we discovered about our patients and their families when we saw them in our role as healers; and we must avoid getting involved emotionally with our patients and their families, must never get sexually involved with them. That’s all we were taught in those lectures.  Not enough guidance about ethical problems, as I soon discovered. Our lecturer was elderly with a monotonous quavering voice, it was hot, late November and summer already was well under way. We were confident that there’d be no exam questions on these lectures, so we switched off our receptors, openly or surreptitiously swotted our medical, obstetric or surgical textbooks for the finals that loomed ominously, barely two weeks ahead.

Despite a disaster in my clinical medicine long case exam when I completely missed a heart murmur, I passed all my exams relatively comfortably and graduated somewhere in the middle of the pack. If it hadn’t been for that missed heart murmur I’d probably have graduated with honours. My class was almost the last before the rules changed, making it mandatory to have a year of supervised hospital internship before being granted a license to practice independently. I collected my medical license the day after the results of our finals were posted and almost before the ink on it was dry, I went off to a country town as a locum tenens, a relieving doctor, taking the place of an elderly GP who fortunately for me had a partner, a middle aged man who’d been in practice there for about 25 years.  I worked there for 3 weeks, long enough to raise money for a holiday before the internship year began, long enough to convince me that I needed much more supervised training, and more than long enough to encounter my first ethical problem.

On my first morning in the practice, I was ordered to continue a course of Penicillin injections that the elderly GP had started a day or two earlier, but on no account to tell the woman getting these injections what they were or why she was having them. The woman was the wife of the mayor and the Penicillin was to kill the gonococci her husband had brought back as a souvenir of a business meeting in Sydney and passed on to her. The mayor’s wife was not stupid. She asked me if I was giving her Penicillin, and if it was to treat gonorrhea that her husband had given her.  I answered truthfully: I said “Yes” to both questions. All hell broke loose. I had done the ethically correct thing, told the truth, but tactlessly, clumsily.  The mayor was a big shot in the town, one of its most prominent citizens, a close friend of the man I was relieving. Their plan had been to conceal this evidence of marital infidelity and I had blown their plan out of the water. It was a shoddy, shabby, shameful plan that deserved to be exposed. If the doctor and the mayor had any integrity and moral courage they would have told the mayor’s wife the truth and asked her to forgive her husband. Truth-telling is almost always the ethically correct choice when communicating unpleasant facts to patients and their families; concealing the truth, fabricating a false cover story almost invariably does more harm than good.  It hardly needs to be said that the truth must be communicated with sensitivity, tact, and empathy. Sadly, these were qualities and skills I lacked in those days of youthful inexperience. Probably the two GPs, the old man I was relieving and his partner who was supervising me, lacked the necessary qualities too.  It was a valuable experience for me: I learnt a little about communicating bad news to people and did better next time the occasion arose.

In 1955-56, I was senior registrar (chief resident) in Northfield Infectious Disease Hospital in Adelaide for a few months during the last-ever epidemic of paralytic poliomyelitis (by the following year we had the Salk vaccine).  It was a very nasty epidemic, mainly affecting young adults about my age at the time, often causing paralysis of muscles required for breathing and swallowing. More than half the cases who had problems swallowing ended fatally despite our best efforts. We didn’t know in those days exactly how polio was transmitted. We used ‘universal precautions’ – gowns, gloves, face masks, and between patients, all of these changed and thorough hand washing in disinfectant. At the time I was courting Wendy, felt I had excellent reasons to go on living and enjoying life. I was terrified that I might get polio, but I did what I had to do without questioning our procedures or inventing excuses to avoid making contact with these critically ill patients. Soon I ran headlong into a conflict between public health law and what I regarded as morally good conduct.  A recently married young man was admitted critically ill. It was clear that he was going to die. His wife of a few months was quarantined at home and desperately wanted to see him. Public health law, which I generally supported and upheld, was keeping them apart, although they’d slept together in the same bed until the day before he was admitted to hospital.  Now he was in strict isolation. I broke the public health law. I smuggled her into the hospital, disguised as a nurse, gave them an hour or so together. He died the next day.

In my year at the MRC Social Medicine Research Unit in 1961-62, I interviewed 98 randomly selected general practitioners in three industrial county boroughs in the north of England, Stoke on Trent, Wigan, and Middlesborough. The main purpose of the interviews was to find an explanation for the sharply different prescribing rates in these three large towns. Each interview lasted about an hour and revealed very interesting information about the GPs’ perception of various kinds of illness, notably chronic aches and pains, ‘bad nerves’, recurrent acute respiratory infections, and methods the GPs used to keep up to date about advances in medical practice. These and other variables such as medical schools they had attended, postgraduate training and their degrees and other qualifications, were related to prescribing rates.  Alas and alack!  I had the GPs consent to interview them, but it wasn’t fully informed consent. Sir George Godber, the Chief Medical Officer of England and Wales, head of the National Health Service, refused to allow the results to be published because I had failed to fully inform the GPs about the real reason I was interviewing them.   

In the early 1970s when I was building up the department of epidemiology at the University of Ottawa, my crown jewel was the survey research group, a team of about 15 people, mostly women who worked part-time. Two of my colleagues trained them and they carried out several elegant and successful household interview surveys.  One population we studied consisted of welfare and working poor families living in subsidized (‘rent to income’) apartments in several high-rise apartment buildings. I worked closely with a child psychiatrist, Dan Offord, and a social worker, Philippe Barette. We published some of our results of these survey based research projects in the Canadian Journal of Public Health. One day one of our interviewers came back from her morning batch of interviews, shocked and shaken. She’d interviewed a family living on the top floor. As she was coming down in the elevator after this interview, the elevator stopped a few floors lower and a man got in. Many of the families in that building were single-parent mother-led, but a few were two parent families, and as it happened the interviewer had met the family, knew this man by sight although she hadn’t interviewed him. He greeted her when he got into the elevator, then turned his attention to the sawn-off shotgun he was carrying, broke it open and loaded two cartridges into its barrels. He was obviously on his way to his work as a bank robber.  We’d had great trouble gaining the confidence of the families in that building, had spent several months getting to know them. In our training sessions we had stressed the importance of preserving confidentiality, established rules during the interviewer training sessions. If interviewers saw evidence of child abuse – cigarette burns on a child’s arm for instance – this had to be reported to the proper authorities.  Otherwise our interviewers were trained to turn a blind eye to most other evidence of illegal conduct, such as trading in marijuana.  What should we do about this episode? No bank robbery or other crime of violence involving a sawn-off shotgun occurred that day or in the next week or so. We discussed the question at a meeting with our entire interview team. Should we be law-abiding good citizens, report to the police that one of our interviewers had seen a man she could identify with an illegal weapon?  Or should we keep quiet, recognize that our good rapport with the residents of this high-rise apartment was hard won but precarious, would be easily destroyed by snitching on an occupant. We had a vigorous discussion, concluded that we should keep quiet.  

In 1972 I was appointed to the US Public Health Service National Institutes of Health Epidemiology and Disease Control Study Section as the ‘Canadian’ representative on this elite research policy and review committee, the arbiter of policies, programs and projects in public health sciences in the United States, and to a considerable extent, beyond, in other countries as well as the USA.  By chance it happened that several of the programs and projects allocated to me for review had obvious or subtle and not so obvious ethical dimensions.  These included studies of the efficacy of experimental therapeutic agents in which academic investigators had close and cosy relationships with pharmaceutical corporations, raising troubling questions about conflicts of interest; a study of a unique small religious sect with lifestyles that denied children and women the same rights as men in that community (women and children were in effect chattels of the men); and several research projects in which investigators would depart from accepted norms and values regarding informed consent.  The chairman of the study section appointed me chairman of a small ad hoc committee to establish some basic ethical rules that we could apply when deciding whether to approve or disapprove research programs and projects.  This was almost 20 years before the NIH began to get serious about ethical criteria as essential ingredients in design and implementation of research in public health sciences.

All these and other experiences prepared the way for me to become an expert, perhaps even an authority, on ethical conduct of practice and research in public health sciences. That phase of my professional life still lay 20 years or more in the future.