Patrick Fiddes and Paul A. Komesaroff
Melbourne, Australia (Winter 2018)
|William Osler at Oxford.|
Apart from Hippocrates himself, William Osler was among the most praised physicians of all time. Like his Greek forerunner, Osler amassed a huge following of loyal supporters, for whom he could evidently do no wrong. One went so far as to suggest that Osler was: “the greatest physician of all time.”
As the centenary of his death approaches, a more sober assessment of William Osler’s life and achievements is warranted. Indeed, a careful reappraisal of the available evidence reveals that the great man was not without flaws. Some more critical commentators have cast doubt, for example, on widely-accepted views about Osler’s knowledge and command of historical literature concerning the philosophy of medicine.
Indeed, Robert Veatch, one of the few independent critics of Osler, has drawn attention to his tendency to dismiss new ideas in medical ethics, thereby limiting his educational philosophy and contributing to his disregard for the ethical writings of significant earlier physicians, such as Gregory, Gisborne, Percival, and Rush. Veatch commented:
Osler was relatively uninterested in the moderns … [He] did not actively enter into conversation with the philosophers of his time and could not therefore break through the barrier that prohibited any significant ethics discussion.1
Osler’s ethical views were shaped by his parents, his faith, his British acculturation, his classicist education, and the voices of two virtual heroes: Thomas Browne and Hippocrates. These influences guided the conduct of his life, his perceptions of virtue and the character traits that reflected his moral goodness and confirm his excellence; “either morally, or intellectually, or in the conduct of specific affairs.”2
However, by avoiding the debates concerning medical ethics, Osler greatly narrowed the educational value of his oeuvre and perpetuated an entrenched, prevailing cultural paternalism that was dismissive of patient rights.3 Such blindness reflected an unquestioned confidence in the moral and social choices of university-trained gentleman physicians who took literally – in its most undesirable sense – the ethical injunction declared in Hippocrates’ famous first aphorism:
Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgement difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals co-operate.4
In fact, to “make” the patient cooperate epitomizes, with precision, Osler’s approach to his hospital patients. This reality flies in the face of a century of sycophantic portrayals of a charming and kind, dispassionate imperturbable professor whose aura captivated his patients.5 One of these proclaimed: “among the many virtues of William Osler was his spontaneous, natural, kindly interest in patients and students, and in people in general.”6
The facts were rather different. Osler’s Johns Hopkins surgical colleague, Dr. Finney, recalled his frequent, disparaging remarks: “[the] more matter-of-fact audience, ‘the dull, stupid public,’ as he was so fond of characterizing it.”7 Finney’s remembrance was overlooked in the accounts of Osler’s teaching, but demonstrate Osler’s failure to intuitively show his celebrated compassion, or admired medical humanism.
Osler himself openly defended such prejudices in “Aequanimitas”:8
From its very nature this precious quality is liable to be misinterpreted and the general accusation of hardness, so often brought against the profession, has here its foundation. Now a certain measure of insensibility is not only an advantage, but a positive necessity… Keen sensibility is doubtless a virtue of high order, when it does not interfere with… coolness of nerve; but for the practitioner … a callousness which thinks only of the good to be effected, and goes ahead regardless of smaller considerations, is the preferable quality.10
This revealing passage displays Osler’s pragmatism, an abiding paternalism, and a hardness and callousness that contradicts the injunctions of one of medicine’s formative ethicists, Thomas Percival.11,12 Although Osler’s ethical transgressions have been generally disregarded in the Oslerphilic literature, their existence was conceded by the biographers Harvey Cushing and Michael Bliss, and by James Wright.13 Even these authors, however, passed over the moral lapses, usually with the help of tendentious, utilitarian “greater good of mankind” arguments.
Among Osler’s more minor moral lapses was his adoption of the widespread and profitable practice of body-snatching to provide corpses for anatomy schools, an activity that reflected, at the least, an uncritical acceptance of conventional medical mores.
Perhaps more concerning was his determination to secure autopsies. Osler’s niece, Marianne, described how he once offered money and an overcoat to an itinerant alcoholic to gain a future autopsy and liver specimen. For her – as for Oslerphiles – this was somehow virtuous behavior. In reality, “ordering an organ in advance,” as Bliss put it, was just the opposite.14
More disturbing still was Osler’s conduct after Alexis St. Martin died in June 1880. On his death, Osler “immediately wrote to a physician and the parish priest urging them to secure [him] the privilege of an autopsy and offering to pay a fair sum for the stomach.”15 Such conduct was regarded even at the time as innapropriate, unethical, and repugnant. Indeed, the patient’s family, anticipating such interest, was forced to resort to hiding the body until decomposition precluded dissection, in order to thwart Osler’s designs.
Even worse behavior occurred after a child’s death from Hodgkin’s disease. Despite her burial, Osler’s wish for an autopsy was secured by the family doctor threatening to foreclose the farm mortgage. To the family’s distress, the girl’s body was exhumed and an autopsy performed.16 Then, as now, such actions were unethical and abhorrent.
It was common knowledge that Osler would apply duress, through his residents or, if they failed, directly himself. “When Dr. Osler wanted to do an autopsy, undoubtedly to advance the cause of science and humanity, his helpers worked hard to get permission.”17
More reprehensible was a consentless secret autopsy.18 Osler removed the adrenal glands of a deceased patient, which, after a priest had obtained consent, was followed the next day with a formal autopsy. Darey, Osler’s student, documented the occasion by providing data for Cushing’s biography.19 Subsequently, the “suprarenals in Addison’s disease” were amongst a 1934 list of Osler’s pathology specimens.20
On yet another occasion Osler requested his student, Ogden, to obtain the brain of a criminal following his hanging: “[Osler] got some sort of letter from the Dominion Minister of Justice … [asking] those concerned… to help… in every way they could.”21 Appalled at the request, the criminal’s priest, the gaoler, and the sheriff all rejected it. Nonetheless, Ogden persisted and, following their departure and the certification of the cause of death, eventually succeeded in retrieving the brain.22
Osler’s conduct cannot be excused as merely reflecting the ethical standards of the day: then, as now, such conduct was illegal and to pressure students to commit crimes was reprehensible. In his remorseless self-justifications Osler argued that his conduct was “[in] the interests of mankind.” However, such claims were in direct conflict with the wishes, values and beliefs of families, lawmakers, the church, and physician-philosophers. None of his actions was justified by the times: they were as wrong then as they would be today.
The examples quoted are among many that now need to be considered as Osler’s legacy is reappraised. They should be added to other lapses of which space does not allow discussion here: his sexism, his haughty intolerance of specialization in internal medicine, and his dogged attachment to accepted historical precepts.
Interestingly, Cushing resiled from expressing his own view about these instances, which were deemed “too indelicate or apocryphal,” and Bliss also recorded them without drawing conclusions.23 Wright commented wryly that the egregious autopsy activities were largely ignored because they “seemed so incongruous with the preconceived notions of the great William Osler,” adding that such behaviour “can most likely be attributed to paternalism.”24,25
This, however, is an insufficient explantion. As in more modern instances, past wrongs cannot be dismissed by retrospectively constructed excuses. In the case of William Osler, the offenses were exacerbated by the trust he created not only in his students and colleagues but also in the generations to follow.
Indeed, perhaps to add insult to injury, such trust even induced nine Oslerphiles to propose that William Osler should be regarded as a great examplar of Aristotelian virtue ethics, proclaiming that his character and behavior reflected both virtue and incontrovertible moral probity.26
However, this is a misunderstanding of virtue and Aristotle’s discussion of it. Virtue concerns both human welfare and dignity in the conduct of one’s life, and the goodness of an action reflects its quality, its application, the rightness of its ends, and its reasoning. Further, Aristotle required virtue to be an intuitive, invariable, and persisting attribute that represents a natural inclination or trait. It must be independent of any other desire, be habitual, and, not a means to some other end.27
William Osler may indeed have been a great man and he may well have made useful contributions to the formation of modern medicine. However, an individual’s status is not enhanced by exaggerating the facts or ignoring countervailing evidence, an observation that applies equally to the status of the discipline of medicine itself. Osler’s acceptance of historical data, and appreciation of his heroes’ contributions, were diminished by apocrypha and the prejudices he was incapable of questioning. It is now time to set the record straight, for the sake of historical truth, the values of science, and the integrity of medicine itself.
- Veatch, R.M. Disrupted Dialogue (New York: Oxford, 2005), 130-5.
- Blackburn, S. The Dictionary of Philosophy (Oxford: Oxford, 2008), 381.
- The Bibliotheca Osleriana is his personal, notated index of his 7500-volume personal library.
- Adams, F. The Genuine Works of Hippocrates (Birmingham: The Classics of Medicine, 1985), 697.
- Abbott, M.E. Sir William Osler Memorial Volume (Montreal: Private, 1926)
- Roland, C.G. Osler, Sir William (Dictionary of Canadian Biography), 1998
- Finney, J.M.T. A Personal Appreciation of Sir William Osler (JAMA. 1921), 281
- The 1989 speech “Aequanimitas,” was his first, and perhaps, most important philosophical address.
- Osler, W. Aequanimitas (Philadelphia, Blakiston, 1905), 5
- Tauber, A.I. Patient Autonomy and the Ethics of Responsibility (Cambridge, MIT Press, 2005), 253.
- Tauber is quoting Thomas Percival from Haakonssen, L. 1997. Medicine and Morals in the Enlightenment: John Gregory, Thomas Percival and Benjamin Rush. Amsterdam. Rodopi.p.217.
- Wright, J.R. Sins of our Fathers (Sagamore Beach, Science History Publications, 2011).
- Bliss, M. William Osler: A Life in Medicine (Toronto, Toronto University Press, 1999). 114.
- Osler, W. A Backwood Physiologist (London, Oxford University Press, 1908). 167
- Bliss, 1999
- Ibid, 140.
- Wright, 2011, 264.
- Bliss, 1999.
- Abbott, 1926.
- Library, McGill Library Osler Letter Index (Montreal), 2005.
- Bliss, 1999
- Bliss, 1999. 114.
- Wright, 2011. 263
- ibid, 267
- Blackburn, 2008
- Aristotle. The Nicomachean Ethics (London, Penguin Press, 2004).
- Abbott, M. E. 1926. Sir William Osler Memorial Volume: Appreciations and Reminiscences. Montreal: International Associations of Medical Museums.
- Adams, F. 1985. The Genuine Works of Hippocrates. Birmingham: The Classics of Medicine Library.
- Aristotle. 2004. The Nicomachean Ethics. Translated by J. A. Thompson. London: Penguin Press.
- Blackburn, S. 2008. Oxford Dictionary of Philosophy. Oxford. Oxford University Press
- Bliss, M. 1999. William Osler: A Life in Medicine. Toronto: University of Toronto Press.
- Finney, J.M.T. 1921. “A personal appreciation of Sir William Osler.” Journal of the American Medical Association 77: 2013- 2019.
- Library. 2005. “McGill Library Osler Letter Index.” McGill University. Accessed July 15, 2015. https://osler-letters.library.mcgill.ca/.
- Osler, W. 1905. “Aequanimitas.” In Aequanimitas and Other Addresses, 1- 11. Philadelphia: P. Blakiston’s Son & Co.
- Osler, W. 1908. A Backwood Physiologist. In An Alabama Student and other Biographical Essays. Toronto: Oxford University Press Canadian Branch.
- Roland, C.G. 1998. Osler, Sir William. Retrieved June 21, 201, from Dictionary of Canadian Biography: http://www.biographi.ca/en/bio/osler_william_14E.html.
- Tauber, A. I. 2005. Patient Autonomy and the Ethics of Responsibility. Cambridge: MIT Press.
- Veatch, R.M. 2005. Disrupted Diagnosis. New York: Oxford University Press.
- Wright, J.R. 2011. “Sins of our Fathers: Two of “The Four Doctors” and their Roles in the Development of Techniques to Permit Covert Autopsies.” In The Persisting Osler IV: Selected Transactions of the American Osler Society 2001- 2010, edited by J. A, & Byran, C. S Barondess, 261- 271. Sagamore Beach: Science History Publications.
PATRICK FIDDES, MB, BS, GCHPE, MHPE, PhD, FRACP, is an associate professor at Monash University in Melbourne, Australia, where he manages over one hundred medical students. His teaching career included over thirty years as a consultant physician in internal medicine in North Eastern Health in Victoria, five years as the Head of General Medicine and Director of Physician Training at Peninsula Health in Melbourne, and seven years as Director of Undergraduate Clinical Education at the Peninsula Clinical School. His interests center on the philosophies of education, the ethical foundations of medical practice, and the history of medicine.
PAUL KOMESAROFF, MB, BS, BSc (Hons), PhD, FRACP, AM, is a physician, medical researcher and philosopher at Monash University in Melbourne, where he is also a professor of medicine. He is a practicing clinician, specializing in the field of endocrinology, and his scientific research work focuses on the effects of hormones on the cardiovascular system. He is also executive director of the international NGO Global Reconciliation and President-elect of Adult Medicine in the Royal Australasian College of Physicians (RACP). He is the chair of the editorial board of the Journal of Bioethical Inquiry and Ethics Editor of the Internal Medicine Journal. He is the author of more than 400 articles in science, ethics and philosophy, and author or editor of fourteen books.