AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. November 2001, Volume 3, Number 11.

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Guarding the Art: Edmund D. Pellegrino, MD

Commemorative Issue: Reconnecting to Essential Ideals

Karen Geraghty

"What you freely assert, I freely deny. Sustain your case!" Pointing his finger at the 12-year-old Edmund Pellegrino, the Jesuit priest at Manhattan's St. Francis Xavier school challenged the boy to think about his answer--to reason and to argue for his position based on logic and evidence, and not to be swayed by mere opinion. It was a lesson the Brooklyn-born son of Italian immigrants would carry with him throughout his life, using it to frame his compelling argument for the moral nature of medicine and the ethical obligations of physicians.

Today, Dr. Edmund Pellegrino is recognized throughout the world as one of the most prolific and passionate spokesmen on ethics and the medical profession. His argument is deceptively simple: medicine is at heart a moral enterprise founded on the covenant of the patient-physician relationship. He has spent a lifetime sustaining his case--in hundreds of philosophical writings, in his clinical teachings to countless students and, most importantly, in the care of his individual patients. His perspective has pitted him against those who would argue that medicine is a business and health care a commodity, subject to the caprices of the marketplace.

Dr. Pellegrino identifies 3 aspects of medicine which define it as a moral enterprise:

First is the nature of illness itself, because it is illness, as a universal human phenomenon, that makes medicine a special kind of human activity. The sick person is in a uniquely dependent, anxious, vulnerable, and exploitable state. Sick persons must bare their weaknesses, compromise their dignity, and reveal intimacies of body and mind. The predicament of illness forces them to trust the physician in a relationship that they would prefer not to enter and in which they are relatively powerless [1].

It is this fundamental vulnerability of the patient and the need for trust in the healing relationship that constitutes the moral imperative for the physician to serve the patient with the patient's best interest in mind.

Second, the physician's knowledge is not proprietary. It is acquired through the privilege of a medical education. Society sanctions certain invasions of privacy such as dissecting and performing autopsies on human bodies, participating in the care of the sick, or experimenting with human subjects . . . to ensure that society has an uninterrupted supply of trained medical personnel. The physician's knowledge therefore is not private property. Nor is it intended primarily for personal gain, prestige, or power. Rather, the profession holds medical knowledge in trust for the good of the sick [2].

By accepting the privilege of medical education, physicians enter into a covenant to use their medical knowledge for the benefit of society.

Moreover, this covenant is acknowledged publicly when the physician takes an oath. . . . The oath--not the degree--symbolizes the graduate's formal entry into the profession. The oath . . . is a public promise--a "profession"--that the new physician understands the gravity of his or her calling, promises to be competent, and promises to use that competence in the interests of the sick [3].

It is these 3 aspects--the nature of illness, the nonproprietary character of medical education, and the oath of fidelity to the patients' interests--that define medicine as a moral community and determine the ethical obligations of the individual physician and the profession as a whole.

According to Dr. Pellegrino however, the prevailing social milieu runs contrary to this fundamental nature of medicine. The legitimization of the profit motive has transformed the patient-physician covenant into the patient-physician contract. He argues forcefully that today's physicians must choose between doing good and pursuing profit. The profit motive is irreconcilable with the patient's best interests because when the covenant between physician and patient turns into a business contract, "the end result is a physician who is an employee whose loyalties are divided between organization and patient, and whose self-interests are pitted against the patient to curb costs or make profits" [4].

Ironically, this elder statesman of the medical profession was almost not admitted to medical school. Despite his outstanding grades at St. John's University, where he graduated summa cum laude, he was not invited for interviews at any of the schools to which he applied. A letter from one Ivy League school complimented young Pellegrino on his grades but declined his application stating that he would be "happier with his own kind." Italians, said his academic advisor, were no more welcome than Jews in the major medical schools, and he might fare better if he changed his name. Pellegrino refused. His admission to New York University Medical School was due in part to his father's ingenuity. A salesman in wholesale foods in New York, the senior Pellegrino approached one of his customers who owned a restaurant near the campus of NYU and asked to be introduced to one of the regular customers. That customer--the dean of NYU Medical School--asked Mr. Pellegrino to send along his son's grade report. The junior Pellegrino was none the wiser and the rest, as they say, is history.

Since his graduation from medical school in 1944, Dr. Pellegrino's career has been as broad as his range of interests. He was president of Yale-New Haven Medical Center, chancellor and vice president for Health Science at the University of Tennessee, founding chief executive of the Health Science Center at SUNY Stony Brook, founder of the Department of Medicine at the University of Kentucky, and president of the Catholic University of America.

But it is his work as a physician with which he most strongly identifies. At the age of 81, he is the John Carroll Professor of Medicine and Medical Ethics at Georgetown University and arrives at the office each morning by 6 AM to sit at his 60-year-old Olivetti typewriter and wage his crusade for the recommitment of the medical profession to its core ideals. A man of deep faith and conviction, he draws on the lesson of his schoolboy days to argue passionately--but with evidence--for the importance of physicians' virtues, such as intellectual honesty and fidelity to the patient, as the ethical basis of the clinical encounter. For him the mandate for professional behavior is straightforward:

To be a professional is to make a promise to help, to keep that promise, and to do so in the best interests of the patient. It is to accept the trust the patient must place in us as a moral imperative, one that the ethos of the marketplace or competition does not expect us in our society to honor. The special nature of the helping and healing professions is rooted in the fact that people become ill and need to trust others to help them restore health [5].

To Dr. Pellegrino, who has honored this trust for decades and has spent a lifetime defining and defending the core values of professionalism, your case has been sustained. QED [6].



References

  1. Pellegrino E, Thomasma D. The Virtues in Medical Practice. New York, NY: Oxford University Press; 1993: 35.
  2. Ibid. 36.
  3. Ibid.
  4. Medical professionalism: Can it, should it survive? J Amer Board Fam Prac. 2000;13:148.
  5. Pellegrino, E. What is a profession? J Allied Health. 1983:(12)3:174.
  6. QED: Latin acronym for quod erat demonstrandum meaning "that which was to be demonstrated," usually placed at the end of an argument or mathematical proof.

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