NOT LONG AGO, A HALF-DOZEN MEDICAL STUDENTS MET WITH Dr. Edmund Pellegrino in a conference room at Georgetown University Hospital to discuss a very sick 94-year-old woman. Demented and dehydrated, she was bleeding internally and had a serious case of pneumonia.
"It's not a dramatic situation, like Baby Fae's," Pellegrino observed, referring to the infant who received a heart transplant from a baboon in 1984, "but it's much more typical."
The woman's condition had deteriorated, and her family wanted to let her die in the hospital. So Pellegrino asked the students gathered around him: "How vigorously should we treat her?"
The students -- calling her Granny Fae -- discussed the alternatives. Forcing his apprentices to back up their positions, Pellegrino asked: "So why do this stuff? Because she's treatable. If she has an ulcer, you can fix it. If she has a tumor, you probably can take care of that, too. There's a medical benefit we can provide -- that's what we mean by the principle of beneficence."
A student reminded the group that the family wanted to let the patient die. Pellegrino prodded again: What did they think of that idea?
"There's no way I'm going to let her bleed to death," one student protested.
"Even if the family says to?" asked Pellegrino.
"If you're not going to transfuse her, then you might as well put a pillow over her head," another said.
"I make a distinction between killing and letting someone die," Pellegrino answered.
"If they don't want to do what I suggest, they should get another physician's opinion," a student said. "Why did they bring her to the hospital, anyway?"
"We were worried," Pellegrino replied, taking on the role of the daughter. "Is it wrong to want your dying mother to go as comfortably as possible?"
The doctor went to the blackboard to begin counting votes. "Okay," he said. "The moment of clinical truth has arrived. What do you do?"
Three students went for no-holds-barred treatment, arguing that's what beneficent doctors are supposed to provide; two opted for minimum efforts, arguing respect for the family's decision. One student hesitated.
"I appreciate your deep involvement in this case," Pellegrino told him, "but you've got to decide." The student waffled. "Medicine is not philosophy," Pellegrino said. "This is why medicine is tough. In a philosophy class, you can argue, 'On the one hand, this, on the other, that.' In medicine, you've got to take a position. And there are always conflicts, conflicts of obligations. You've got to resolve them. That's what medical ethics is all about."
The last vote came in for minimum treatment. Then Pellegrino divulged his own vote. Doctors could do nothing to return the patient to good health. The end of this patient's long life was near. The family, with guidance from doctors, had made a responsible decision to let their mother die.
IN MANY CASES, high-tech medicine now makes a patient's life or death a matter of deliberate choice. It also transforms medical ethics. Edmund Pellegrino is devoted to helping doctors learn how to think about choices they face in the new era of medicine. He is also convinced the topic is too important to leave to doctors.
Pellegrino pushes everyone to take up the tradition of Socrates and learn how to think ethically. Each of us, he says, whether doctor or patient, carries a distinct set of values. Sooner or later, we will face a hard choice about life or death that no one else can make.
Every month, Pellegrino accepts about a dozen invitations to speak. When he opens the floor to questions, he is often asked about letting patients die. He is asked whether doctors should remove the respirator from a coma patient like Karen Ann Quinlan, whose case in 1975 drew attention to the problem. Later he says the Quinlan case posed a choice between permitting death with dignity and prolonging life without humanity. He would have voted to remove her respirator.
He is often asked whether doctors should let a handicapped newborn, say with Down's syndrome and a blocked but fixable esophagus, like the infant known as Baby Doe, die of starvation, as the Indiana Supreme Court permitted in 1982. Pellegrino bristles at the ruling. The case, he believes, provides a warning that some infants need help to protect them from harsh judgments of disappointed parents.
But instead of declaring what he holds right or wrong, Pellegrino treats the people in the audience like med students. Insisting everyone is a philosopher, he stirs the audience to do ethics.
He wants them to understand that there are different ways to think about "doing good." For one person it can be helping a patient at all costs. For another, good may emerge when the costs are less than the benefits. There are also different theories of ethics: some focus on rules, some on consequences.
At bottom, he asks, is the conflict based on different "images" or "ideas of man"? A Catholic's image may lead him to oppose abortion, even when it is medically called for. An Orthodox Jew's leads him to challenge anything that might shorten a life. A Jehovah's Witness' idea of man prevents him from ever accepting a blood transfusion.
In Pellegrino's view the conflict is likely to involve one of the three issues that define medical ethics today. First, there is the changing nature of the relationship between doctor and patient. What was once a healing profession is in danger of becoming applied biology. What was born of a 2,500-year-old covenant, the Hippocratic Oath, is turning into an arm's-length transaction at clinics offering the medical version of fast food, or a testy encounter conducted by lawyers at the malpractice bar.
Next, there is what Pellegrino calls the changing locus of decision. Who decides how vigorously to treat a patient? The extremes run from the old-fashioned practice of beneficence, and complete control for the doctor, to the modern notion of autonomy for the patient -- and Pellegrino sees problems with both. How can a doctor judge the good of the patient without involving him, or his family, in the decision? How can the patient or family know enough about medicine to choose the right care?
Finally, there is the conflict raised by the high costs of modern medicine. Pellegrino sees a clash between society's need to curb costs and the doctor's duty not to consider costs every time he decides how to treat a patient. He is particularly concerned about the influence of economics on would-be doctors. "Too many of them already think like businessmen," he says. "Their values are screwed up."
ONE MORNING on rounds, Pellegrino was asked where he learned to frame issues the way he does. He told the following story:
"My first day at St. Francis Xavier High School in Manhattan, I was 12 years old, and I made a statement. The young scholastic at the Jesuit school turned on me and said" -- Pellegrino whirled, pointing his finger at an imaginary student -- " 'What you freely assert, I freely deny. Sustain your case!' I was floored. I didn't know what he was talking about. Then he asked, 'How do you know that? What's your evidence?' I fumbled, he pierced my logic, and I began to learn how to think."
The doctor is a short, wiry man, with ramrod posture, and the blunt, sloped features of a boxer. He can be charming, impatient, nervous and shy. He is modest, brisk and intense. He has deep-brown eyes, a mole on one cheek and a dimple on his chin, and he wears chalk-smudged suits and well-worn loafers. Instead of walking, he scoots and bounces. "I played quarterback in football and shortstop in baseball," he says, "the positions that fast, little guys played."
For more than half a century -- he is 65 years old -- he has been active in a variety of fields. Wherever he has been posted as a physician, including New York, Alabama, New Jersey, Kentucky, Long Island, Tennessee, Connecticut and Washington -- in that order -- he has maintained a lab to keep up his research in chemistry. It was his major at St. John's University, in the New York City borough of Queens, from which he was graduated summa cum laude in 1941. He chose medicine over law or the church, because of his passion for scientific research. But, since graduating from New York University's College of Medicine in 1944, he has also concentrated on what he calls "the humanities."
His is a literal use of the term. When the doctor boasts he has an exquisite sensitivity to language, he means a scientist's taste for precision more than a poet's ear. Words like "echolalic," "obtundation" and "propaedeutical" show up regularly in his vocabulary because they express what he intends. There is nothing casual about his talk. It is not unusual for him to answer a phone call, listen for a while, and exclaim, "You must be in a state of physiological disarray!"
He reads history, novels, poetry and philosophy in seven languages, and writes about medicine and man in a dense, purposeful English. After 277 articles (some of which come off like bombastic lectures, because that's how they began), he has perfected the affirmative in a debate he revived almost single-handedly. It could be advertised under the banner "Resolved: That the physician who does not understand his own humanity cannot heal another's."
Pellegrino summed up his ideas in a volume called Humanism and the Physician and, as coauthor with a former Dominican friar named David Thomasma, in A Philosophical Basis of Medical Practice. (They recently finished a sequel called For the Good of the Patient: The Restoration of Beneficence in Medical Ethics.) By the doctor's measure, the books reveal the defect in his classical education. They brim with principles, and thirst for solid examples. "I find examples imprisoning," he admits. "I can never get the right ones."
To a number of philosophers, his books offer a large dose of empathy and not much rigor. They reveal a Pollyanna's faith in the ability of the humanities to improve the character of physicians. But many scholarly reviews treat them as milestones in the literature of medicine -- the first attempts in more than 50 years to offer a philosophy of medicine.
Although Pellegrino believes in the force of ideas, he has been an aggressive promoter of his own. Dr. Gert Brieger, who directs the Institute of the History of Medicine at Johns Hopkins University, says Pellegrino is doing for medical ethics what Ralph Nader did for consumerism. His ideas are sought out daily. When Dr. George Lundberg, who edits the Journal of the American Medical Association, needs a second opinion on whether to publish an article submitted on medical ethics, he turns first to Pellegrino.
But there is more to the mind of Pellegrino than medicine and ethics. In 1980 Daniel Boorstin, the librarian of Congress, formed the Council of Scholars to meet twice a year and inventory the state of mankind's knowledge and ignorance. He appointed Pellegrino to the 27-person board. "He's extraordinarily able," Boorstin explains, "and he knows about so many different things."
Pellegrino keeps up his wide interests for straightforward reasons. "My ego boundaries are way out there," he says. The Latin dictum on his bookplate, which shows a monk alone in a quadrangle, translates, "Live as if you'll die tomorrow. Learn as if you'll live forever," and the doctor follows it like a prescription.
Almost every morning at 4:30, he is up, cogitating and writing. On an old Olivetti portable, he types his thoughts. He copies by hand passages from his reading, like the one from St. Thomas Aquinas that he adopted as a motto -- "The purpose of the intellect is to put things in order."
THE NINE-PAGE epilogue to Humanism and the Physician describes the elements of Pellegrino's credo. Although he is a devout Catholic (a photograph of him kibitzing with Pope John Paul II hangs in his office and, until he resigned after four years in 1982 to join the Georgetown faculty, he served as president of Catholic University), these views go beyond his faith. They grow from his observations about doctors and patients.
"If we are to know something about what it is to be a physician," he writes, "four words in common parlance are in need of rehabilitation." The words are profession, patient, compassion and consent; the cardinal definition is of the first. Redefining it by the Latin root, he strives to remind doctors that medicine is a calling.
Someone sick asks for help and, with compassion, a physician applies his skills as best he can. The physician "binds himself to competence as a moral obligation." He "places the well-being of those he presumes to help above his own personal gain." Pellegrino goes on, "If these two considerations do not shape every medical act and every encounter with the patient, the profession becomes a lie: The physician is a fraud and his whole enterprise undiluted hypocrisy."
Pellegrino honors his oath by working on the wards at Georgetown University Hospital two months a year. He also answers frequent calls from former patients who want to hear what he has to say about how their latest ailments should be treated. His beside manner is soothing and animated; he prides himself on making swift, accurate diagnoses.
In fact, doctors take his stern diagnosis about medicine surprisingly well. They applaud him as a statesman of the profession. But Pellegrino is not confident they get his point. If they did, they would realize what he has warned for a generation: Doctors must choose between doing good and pursuing profit -- to avoid what he calls the "conflict of canons" and fulfill the most nettlesome tenet ("In purity and holiness I will guard my life and my art") of the Hippocratic Oath, which is the touchstone of medical ethics.
A PSYCHIATRIST taking Ed Pellegrino's history would press him on three major events in his life: How he ended up at NYU med school; why he believes getting tuberculosis was good for him; and what he thinks about the quintuple heart bypass operation he had 2 1/2 years ago.
"At St. John's," Pellegrino says, "I was second in my class -- first in the sciences -- and around March, the spring I was going to graduate, I hadn't been invited for interviews by any of the med schools I applied to. One Ivy League school sent me a letter praising my record but telling me I'd be happier 'with my own kind.'Another didn't bother to answer my application. My adviser thought the problem was cut-and-dried. He said Italians had even more trouble getting into medical school than Jews and suggested I change my name. I wouldn't do it.
"My dad was a wholesale grocery salesman, and one of his customers in Manhattan was the owner of a restaurant in Washington Square, near the main campus of NYU. Dad introduced himself to an NYU dean who was a regular at the restaurant, and the dean asked him to send on my report cards. I didn't know a thing about it."
Pellegrino contracted tuberculosis when he was a resident at Bellevue Hospital Center in New York: "I knew right off what was going on, because I spit up blood. Then a friend and I read my X-rays. The friend was Bill Hubbard, a fine doctor who went on to become the chairman of the board of Upjohn, the drug company. The only question was how long I'd be laid up and what would happen to me after. Bill said, 'Well, three years, huh?' and I said, 'Yup, three years.' " Pellegrino withdrew from what he had been doing and learned he was expendable.
"And it was a useful experience, the proverbial hand in the pail of water. You know the old expression, 'You make as much impression in life as a fist in a pail of water'? Getting TB allowed me to think about what kind of a doctor I wanted to be."
From the day he was pronounced fit after tuberculosis, until a few years ago, Pellegrino rarely lost a day to illness. Then he had symptoms that led to open heart surgery: "When I got some symptoms, I had a good idea why. I didn't need to have anything done right away, but I figured, 'Why wait for the event to occur? Why wait for an attack?' I knew the morbidity rate for the operation was fairly low, and I figured, 'Let's do it.' I took the radical approach, in the sense of going to the root of the problem. Everyone warned me that I would be depressed, but I wasn't. I had the procedure, and two weeks later I was back at work. I was eager to assert myself."
He cites his own illnesses to explain the importance of medical ethics: "The power of medicine is unprecedented. When I got tuberculosis, we were just at the start of the era of antibiotics. If there hadn't been antibiotics, my doctors would have caved in my chest. They would have removed five ribs and crushed my chest to close the cavity, and, if I'd had that done to me, I'd probably be dead now from emphysema. On top of the advances from antibiotics, surgeons now know how to invade every body cavity. I had a quintuple bypass operation to repair my heart. That would have been unthinkable when I was a student. In many cases, doctors can now treat cancer and greatly extend a patient's life. High-tech medicine has made life and death a matter of deliberate decision. Each of these steps brings new issues for medicine, and choices, and they all have an ethical dimension."
THE ETHICS ISSUES engaging Pellegrino often have involved doctors and money. In 1957, when he was the precocious director of medicine at a rural hospital in New Jersey, the members of the staff decided they should earn higher salaries. Pellegrino informed them they already made plenty. He announced he didn't want to represent a group that put mammon over morals and handed in his letter of resignation. It was rejected by the staff and returned with a plaque extolling his virtues.
Pellegrino endured his most rancorous years during the early '70s, when he was at the State University of New York at Stony Brook. On the way to building one of the first modern medical schools to require its students to study both the humanities and the sciences, he ran into a host of problems. The price of building the medical center doubled and its capacity decreased by 30 percent because construction began four years late. An angry Pellegrino charged the State Assembly, which he saw as the culprit, with "an act of public immorality." A round of acid exchanges followed.
In such combat, Pellegrino is tough. Although he tries to keep his temper in check, he can be a shrewd infighter.
He takes steps to protect his family from the consequences. He has been married for 42 years to the former Clementine Coakley, who now oversees the rare book collection at Georgetown's medical school library; after losing a son to a heart attack in 1980 (he was 33 years old), the Pellegrinos have six living children, ranging in age from 24 to 41. The doctor reminds them about his attitude on independence: " 'Don't follow the crowd,' I tell them. 'If everyone's doing it, it's probably not worth doing.' "
His family treats his convictions about medicine, and almost everything else, with public pride and private irreverence. At a party he gave to celebrate his wife's birthday, Pellegrino clinked his glass to quiet the crowd and start a round of toasts. "We don't need any more speeches from him!" one brother yelled. (The doctor has three brothers -- Robert is a maritime lawyer, Richard is a pediatric neurologist, and, following their father, Albert is in the wholesale food business.)
When the immediate family gathers for holidays, the older children (Thomas is a neurologist and Virginia, a hospital administrator) are willing to talk medicine, but the younger four (Michael is an architect; Andrea, a writer; Alice, a graduate student in classics; and Leah, a librarian) usually will have none of it. That's fine by Pellegrino. He has other subjects to pursue, teaching something to his 5-year-old grandson Daniel, say, or working with his daughter Alice on a translation they're doing together. It's of a Latin essay about the origins of medical ethics by an obscure Roman named Scribonius Largus. Or, to a chorus of hoots or cheers, depending how things turn out, he takes charge of the cooking.
He's generally in motion, and the family serves as his gyroscope. Clementine Pellegrino, who is kind, calm and good-natured, says, "He doesn't turn his motor off, and rarely puts it on idle." Sooner or later, he slips away -- to study one of his rare books or to play chess, to work out a phrase of Bach's on the piano or of Pellegrino's on the typewriter.
Nicolas Pisacano, a friend of Pellegrino's who runs the American Board of Family Practice, says, "He's not a guru-type guy; he's just solid. He knows medicine cold, and everything he does is the right thing. I can't really explain it. I can buy the goddam brains, but I can't buy another Pellegrino."
Pisacano wasn't referring to the fact that Pellegrino serves without fanfare on the boards of three dozen organizations (for example, the International Hospice Institute, the Catholic Health Association's Task Force on Health Care for the Poor) whose causes he believes in. Nor was he making the point that the doctor passes up magazines, mysteries, TV and the sports page.
Nor did he have in mind Pellegrino's kind of alertness, so that, when he spots a pin sticking out from somebody's new shirt, he picks it off ("Am I not a good doctor?"), or, if a crisis flares up in the room where he's sitting (at a reception, the hostess sent the Sterno burners rolling when she knocked over the hors d'oeuvres table), he's the one to snuff it out. (Hostess: "All I did was blow!" Doctor: "Well, at least we know you don't have emphysema.")
Pisacano was thinking of a more basic trait. At a seminar one evening, while Pellegrino was in the middle of answering a question, a doctor walked out of the room. He had been sitting up front, so everyone noticed and wondered what was happening. "He's an old friend who tells me he's got to go pick up his wife," Pellegrino explained, pausing for effect, "but I'm not sure."
The line was neatly delivered, and the audience laughed. Afraid that he had gone too far (primum non nocere -- that is, the first thing is to do no harm), Pellegrino back-pedaled. "No, really," he said. "I trust the doctor."
Another day, Pellegrino was talking in his office. He was asked to confirm some facts, and he rattled off: "Who wrote Ivanhoe? Sir Walter Scott. Buddenbrooks? Thomas Mann. No. I'm sorry. Ask away."
Then his secretary interrupted to tell him about a phone call he didn't want to take. He looked at his guest and back at his secretary, and said, "Tell them I'm with a patient." He smiled, and his forehead wrinkled. "No, I'm sorry. We'd never tell a lie." Another smile: "Tell them I'll call back as soon as I can. 1987. No, really . . . "
SEVERAL YEARS AGO, Pellegrino put his thoughts about doctors and money on paper. He called the essay, "Medical Morality and Medical Economics: The Conflict of Canons." The cause for the doctor's concern is the "medical-industrial complex," symbolized by the steady rise in health-care costs from 5.3 percent of the gross national product in 1960 to 10.8 percent in '83.
The current wisdom is that competition in health care is the best hope for curbing this rise. The dominant tools in the new health market are for-profit hospitals that now provide about 10 percent of the country's hospital beds. According to the American College of Hospital Administrators, they will control a full 60 percent of available beds within a decade.
To the liberal opposition, these hospitals are turning doctors from public good to private gain. Driven by the market, the doctors who staff them favor high-cost, high-profit procedures for patients with acute problems that can be quickly cured, and they dump patients with lingering ailments like congestive heart failure or chronic kidney disease.
Concludes one op-ed article: "Competition has its place, and efficiency is needed," but not at the cost of "accessible, high-quality care."
Pellegrino disagrees with both the current wisdom and the liberal opposition. To his mind, the competitive principles of the business world contradict the ideal that a doctor's duty is to serve his patients and costs be damned. "Covenant gives way to contract, law replaces ethics, and self-interest becomes a primary rather than a secondary motive."
Worse, doctors cut corners on patients who can't pay, or refuse to treat them at all. In 1982, according to the New England Journal of Medicine, 6 percent of American familiesthought they needed care and couldn't get it. In 1983, the last year for which numbers are available, the fraction jumped to 14 percent, and doctors say it is still climbing. Thirty million Americans now have no medical insurance. Doctors average $108,400 a year in net income, the American Medical Association reports, but in Washington, according to an informal survey by Dr. David Hilfiker, about half the physicians don't accept Medicaid patients because the fees are too low.
Pellegrino believes the only solution is compulsory national health insurance, with free coverage for the poor, a ban on for-profit hospitals and wide availability of care in community-run hospitals for everyone who needs it.
In the Reagan era, this amounts to heresy. It is also considered naive. Pellegrino answers, "Let's get it right conceptually, and then we'll worry about the politics." When doctors are governed by economics, he says, they turn into budget officers and end up treating patients like good and bad accounts.
For the patient, Pellegrino insists, medicine is a right as basic as the ones defined by the Constitution. For the doctor, it is a public trust to use for the common good. Hence the need for a national health plan.
TO PELLEGRINO, this is ethical thinking. The exercise gets him worked up. Sometimes when he lectures, his hands fly and he knocks off his microphone -- with an impatient aside like "Technology!" -- before launching into the close of his spiel. At Johns Hopkins University in Baltimore one evening, Pellegrino wound up a talk to a full house. In attendance were the hospital's senior administrators, doctors, nurses, students and, via closed-circuit TV, patients. Pellegrino's adrenaline was high.
"One can conceive of a circumstance in which this country could decide that we are not going to make kidney dialysis available for some people," he declared. "I think that's one of the biggest dodges ever. We keep talking about the cost of dialysis, which is $2 1/2 billion a year, but we spend that much a year on dogs at the track. We spend $40 billion a year on alcohol, $50 billion on tobacco, $65 billion on cosmetics, $70 billion on gambling, $80 billion, minimum, on illicit drugs -- and the National Rifle Association won't tell me what we spend on guns.
"I'm not saying that people should deprive themselves of these things. But, before we cut back on health care for some patients because of cost, we have to decide where on our scale of values medicine and health care fit. What kind of society do we want?"
ON THE ROAD back to Washington, the doctor is asked if he ever feels like a scold.
"You know Robert Bolt's A Man for All Seasons?" he replies. "At the end of the play, after they've chopped off Sir Thomas More's head, the Common Man turns to the audience."
The Common Man is a wry, cynical character who narrates the play. Pellegrino takes up the part. "He says, 'It isn't difficult to keep alive, friends -- just don't make trouble -- or, if you must make trouble, make the sort of trouble that's expected.' "The capacity to make moral judgments, and to be self-critical, is part of being an educated person, and I like to know where I stand. That's what I do with ethics. I don't set out to make trouble, but, when I do cause a stir, it's only because I raise questions that strike me as unavoidable.
"For me, ethics is always part of a much larger question of philosophy of medicine. I prefer -- doctors don't like this -- to think in terms of moral philosophy rather than ethics. They say, 'Ed is a moralist, and not an ethicist, more Cicero than Aristotle.' The philosophers criticize me, too, because they prefer a language game they call analytic philosophy. They look at the meaning of terms, because they don't believe it's possible to understand the real world.
"In fact, there's just as much analysis in what I do, but not for its own sake. It's a step to an enterprise that others have abandoned to which I hold allegiance, which is to derive universal principles about the world. That's the real project of philosophy, to get at some values that are unchanging."
The doctor laughs. "Well, that's very hard to answer. They're founded on such simplicity they sound trivial. Truth. Beauty. Justice. That sort of thing. One of the major functions of philosophy is to contemplate and recontemplate the obvious. But I wouldn't go around yakking and getting vexed if I thought nothing would come of it."
He pauses for a moment, and says, "They made that play into a movie, didn't they? That was some years ago."
About 20, he's told.
"As a matter of fact, I think it was the last movie I saw."