The ethics of entrepreneurial medicine

Abstract

To present this lecture in place of Dr Francis D Moore is a great privilege. My sense of privilege calls to mind Dr Moore’s splendid autobiography, A Miracle and a Privilege. In that book he set out a fascinating account of his life in clinical surgery, research, teaching, and administration. Dr Moore developed at Harvard and its hospitals an uncommonly favorable climate for biologic investigation so that his own work and the work of many other investigators flourished. The results of that research facilitated a new era of surgical biology, noted by a cover story about Dr Moore in a national weekly news magazine. The thrust of the cover story indicated that surgical operations had already been made safe for the patient, and in this new, biologic phase of surgical science we were aiming to make the patient safe for the surgical operation. During the American College of Surgeons meeting in San Francisco 9 years ago, we heard the exciting news of the Nobel Prize award to Joseph E Murray, FACS, a member of Dr Moore’s department and another exemplar of the productive fusion of bench research, clinical investigation, and compassionate patient care, all subsumed under an individual ethic that puts the patient in first place. Now we have come to an era of overarching technology, juxtaposed with a phase of commercialization, consolidation, and merger mania in our daily lives, and mutatis mutandis in the field of medical care. Underlying these radical changes is the bedrock of our moral foundation, which Dr John J Conley wisely and generously recognized by his support of this ethics and philosophy lectureship and by many other philanthropic endeavors related to ethics during more than half a century as a Fellow of this College. At the time of his recent death, Dr Conley was emeritus professor of otorhinolaryngology at Columbia Presbyterian in New York and a poet of substantial accomplishment. His books of poetry entitled Word Paintings underscore his emphasis on the liberal arts. He inspired a host of admirers by his generosity and his professional achievements. The title of Dr Moore’s projected lecture, “Ethics: From Percival to G.B.S.,” implies that many physicians are aware of Thomas Percival and his assignment by the trustees of the Manchester Infirmary in England to draw up guidelines for the conduct of the Infirmary’s physicians in the late 18th century. Percival admonished staff physicians to behave politely so as not to bring discredit on the medical profession by fighting over hospital privileges. The Infirmary’s services had been seriously strained by an overload of patients incident to an epidemic of what was probably typhoid fever, and hospital authorities increased the staff roster with practitioners whose capacities the established staff considered inferior in quality to their own. Percival was not writing originally about ethics in the present sense but rather about etiquette among physicians. The word ethics did not appear in his initial presentation, and a concern about patients was not a focus of his original stipulations. Early ethical pronouncements of the American Medical Association borrowed heavily and even explicitly from Percival’s early formulation, so that we had for many years a confusing mix of ethics and Based on an Ethics and Philosophy Lecture delivered at the Clinical Congress of the American College of Surgeons in San Francisco, October 13, 1999.