The Good Doctor

The death on June 13, 2013 of Dr. Edmund Daniel Pellegrino portends the end of an era. A remarkable physician and humanist, one of the founding figures of the field now known as bioethics, by turns a department chair, dean, university president, and director of an ethics think tank, he wound up denying that he ever was a “bioethicist” while never ceasing to be one of the best, as well as one of the first, upon whom the title could be bestowed.

Pellegrino was born on June 22, 1920 in Brooklyn. He attended Xavier High School in Manhattan, received an undergraduate degree from St. John’s University, and a medical degree from New York University. He interned at the famed Bellevue Hospital and, after a brief stint at a tuberculosis hospital, returned to Bellevue and NYU, specializing in internal medicine and the physiology of calcium in the kidney. Thereafter, he embarked on a career in academic medicine that would take most people several lifetimes to accomplish. He launched the primary care program at the hospital in Hunterdon, New Jersey, and before he was 40 became the first chairman of the department of medicine at the University of Kentucky. He was the first dean of Stony Brook University Medical School, chancellor for health sciences at the University of Tennessee, president of the Yale-New Haven Medical Center, president of the Catholic University of America, director of the Kennedy Institute of Ethics at Georgetown, and founder of Georgetown’s Center for Clinical Bioethics, which was recently named in his honor. He received fifty-four honorary doctorates and numerous prestigious awards from medical associations and bioethics institutes. He was a member of the Institute of Medicine and a Master of the American College of Physicians.

Pellegrino began writing on the subject of medical ethics in the late 1950s, well before the word “bioethics” was coined. In 1969, he helped to found the world’s first formal bioethics society, the Society for Health and Human Values (precursor to the current American Society for Bioethics and Humanities), and served as its second president. He was founding editor of the Journal of Medicine and Philosophy and a regular contributor on ethics for the Journal of the American Medical Association. He served as chairman of the President’s Council on Bioethics during the second term of President George W. Bush, and as a U.S. representative to UNESCO for the development of its Universal Declaration on Bioethics and Human Rights.

An accomplished scientist and consummate clinician, Pellegrino still ran a lab while president of Catholic University and saw patients into his 90s. He was a scholar and teacher of extraordinary talent. His writings — twenty-three authored or edited books and over six hundred scholarly articles — were prolific and influential. He was a tireless lecturer of immense enthusiasm and a generous mentor to physicians, graduate students, and anyone who came to his office seeking advice and counsel.

He was also a deeply committed Catholic — Jesuit-educated, Thomistic in his philosophical temperament, active in an Archdiocesan program providing free care to the indigent of Washington, an advisor to bishops and to the Vatican.

He saw an enormous number of changes over the course of his lifetime — in medicine and in the culture at large. He was born between world wars, lived through the entire course of the Cold War, and died during the ongoing fight against terrorism. He had trouble being accepted to medical school because his last name was Italian. He began practicing medicine in an age before antibiotics or CAT scans or cardiac bypass surgery or effective non-surgical treatments for cancer. He was born at a time when abortion was still illegal and almost universally considered immoral and died just after the first human embryo was cloned to make stem cells for research.

Pellegrino’s contributions to bioethics were immense. His approach was founded upon a strong sense of realism about disease and about human beings. At the heart of his ideas were the notions that medical ethics could not be separated from the philosophy of medicine, and that a phenomenological understanding of the fact of illness and the physician’s response to the vulnerable patient’s plight must provide a basis for medical ethics. He believed medicine had a definable telos — healing the sick — and that medicine therefore had an internal morality based on the reality of the human experiences of illness and death and on the goals of medicine as an enterprise established in response to these predicaments. His views were received as intuitively plausible when he began writing in the 1950s and 60s, yet widely acclaimed as unique because no one had ever before quite reflected on these notions in such depth. As he said toward the end of his career, “The Western world has witnessed 2,500 years of medical morality, but only 50 years of medical ethics.” He aligned himself with traditional Hippocratic moral views about medicine. Cognizant of the fact that codes of ethics do not provide rigorous philosophical justification for the precepts they contain, however, and sensitive to the fact that such justification was especially required in our increasingly skeptical world, it was just such justification he set out to provide.

In developing this philosophical justification, he thought not just as a philosopher but always also as a practicing physician. In books such as A Philosophical Basis of Medical Practice (1981), coauthored with his late collaborator, David Thomasma, he laid out the basis for considering what medicine is, defended the primacy of the art in medicine (howsoever informed it might be by science), outlined the “anatomy” of clinical reasoning, and argued that the aim of all clinical actions ought to be “a right and good healing act, for this patient, in these circumstances.”

As the field of bioethics came overwhelmingly to prioritize patient autonomy, Pellegrino continued to defend the primacy of the patient’s good as the central focus of medical ethics. In For the Patient’s Good: The Restoration of Beneficence in Health Care (1988), also written with Thomasma, he set forth a fourfold notion of the patient’s good, consisting, in ascending order of importance, of the patient’s biomedical good, the particular good as understood by each individual in the clinical circumstances, the good of the patient as a dignified person, and the ultimate good — as the patient understood it — whether religiously or secularly. Thus, if a Jehovah’s Witness were to refuse a blood transfusion, which would help her biomedically but violate her conception of the highest good, a physician who honored that refusal could still be understood as acting beneficently.

Pellegrino also became a great champion of the role of virtue ethics in medicine, both in his writings and in a popular lecture on the topic over a succession of annual Intensive Bioethics Courses at the Kennedy Institute of Ethics. His teleological approach to medicine easily accommodated a virtue-ethics view. For Pellegrino, virtues such as competence, compassion, fidelity, integrity, respect, phronesis (prudence, or a practical wisdom), and self-effacement characterized the good physician; these virtues expressed excellence in achieving the healing ends of medicine. Moreover, anyone who knew Pellegrino also recognized how much he himself exemplified these virtues and served as a true role model of the good physician.

He was fully convinced that the healing mission of medicine precluded abortion, euthanasia, and physician-assisted suicide. Hewing to a consistent “seamless garment” approach to these issues, he just as vigorously opposed physician participation in capital punishment and advocated broader access to health care for all.

Pellegrino was deeply concerned by the commodification of healthcare and the “proletarianization” of physicians. He contested the contemporary tendency to recast physicians not as professionals but as employees who could be manipulated by appeals to their self-interest into gatekeepers who would deny patients potentially beneficial services in the name of cost-containment. He championed a professionalism marked by the primacy of patient welfare and demanding at least a modicum of altruism on the parts of those who had sworn oaths to care for the sick. Cost-containment, on his view, was only ethical as a side-effect of practicing good medicine. Good medical practice, as he argued, is always characterized by “therapeutic parsimony and diagnostic elegance,” aimed not at saving money but at what would be best for the patient, since too much testing and treating can be harmful. Such views are now cynically derided as “nostalgic professionalism.” Pellegrino considered these views not nostalgic but a reiteration of some of the timeless truths about the profession that have, from time to time over history, been denied or forgotten by physicians and the societies in which they practiced. He saw himself as one calling medicine back to its normative center.

These positions earned Pellegrino a reputation as a “conservative” in bioethics, placed by some at the margins of the field he had helped to inaugurate, a field that gradually came to reinvent itself as a mainstream academic endeavor controlled by all the usual dogmas of political correctness. His voice, however, was so clear, his arguments so rigorous, and his common sense so powerful that he could not be dismissed. While sometimes subjected to flagrant anti-Catholic bias, he never returned calumny for calumny, and disarmed many of his opponents by his sincere interest in rational argument rather than political posturing.

The life he was able to live, in virtue of the times through which he lived, may well be impossible to live today. Department chairs in medicine are now often best understood as managers of large business enterprises rather than master clinicians and intellectual leaders. The competition for funding in medical schools and the structure of their financing would seem to make it impossible now for any faculty member to conduct basic research, see patients, and do serious work in the philosophy of medicine and medical ethics. Given his traditional views on many current topics in medical ethics, his articles today might have trouble being accepted in major journals.

Or maybe the real story is that there just isn’t another Ed Pellegrino around today who could do all these things and do them all so well.

Despite being one of the founding figures in the field of bioethics, he abjured the title “bioethicist,” preferring to think of himself as a physician and part-time philosopher. For those of us he has left behind working in this messy field, it will be hard, despite his protestations, to conceive of a bioethics without him.