Daniel Sokol on William Osler’s legacy and medical ethics

This is a version of a lecture given to the Osler Club of London and the British Society for the History of Medicine on 1st October 2020 as part of an online conference to celebrate the legacy of Sir William Osler 100 years on from his death in 1919.

I’m a medical ethicist and a lawyer specialising in clinical negligence.  I want to tell you about a recent client of mine, whom I shall call Mr T. 

Mr T has given me permission to tell his story.  

When I first came across Mr T a few years ago, he was 62. He lived alone and suffered from depression. He had a difficult life, plagued by an abusive father, homelessness, alcoholism, long term unemployment, relationship and behavioural problems, anxiety, and depression.

A few months before our meeting, Mr T had asked for his medical records as part of an application to move into a new council flat. As he went through his records, he found a letter, dated 20th August 1968. He was 13 at the time. The letter was written by a surgical registrar and addressed to his GP. It read as follows:

20th August 1968

Dear Dr,

This is a very curious state of affairs.  Mr [Consultant Surgeon] thought this lad looked a bit odd when he came in for his bilateral orchidopexy and we arranged for him to have a buccal smear. […]

Shortly after the operation we were informed that he is, in fact, a nuclear female, probably a Klinefelter, though this is by no means confirmed yet. […]

We had a discussion about this and I would have thought it probably best to say nothing to the parents or the patient at this stage as it can only lead to needless worry about an untreatable condition.

When Mr T read this, he had never heard of Klinefelter’s but wondered whether this could explain why his body had no hair (he had never gone through puberty). Why he had breasts and feminine features? Why he had a micropenis? Why he was picked on at school and beaten by his father, who forced him to take up boxing to “man up”.

Is this why he suffered all his adult life from emotional and psychological problems?

Mr T went to his GP with the letter and soon after was diagnosed with Klinefelter’s syndrome, a genetic condition in which a man is born with an extra X chromosome. The main treatment is testosterone replacement therapy. This was also the treatment in 1968, contrary to what the surgeon told the GP in his letter.

Over the next 50 years, Mr T visited his GP practice about 350 times with all sorts of complaints from palpitations to anxiety. Several doctors expressly referred to the suspected Klinefelter’s in their notes but not a single one told him about this. No one referred him to an endocrinologist or a geneticist.

For example, in 1986 his exasperated GP referred him to a psychiatrist, writing in the referral letter:

It is totally impossible to make head or tail of his symptoms, which are obviously aggravated by anxiety and depression if not caused by them.

The only clue I have to this awful mess is that in 1968 he was found to be probably Klinefelter’s. Do you think this is the underlying problem?

Last year, Mr T started on hormone replacement therapy and he is a completely changed man. The effectiveness of the treatment in his 60s strongly suggests that it would also have been effective in his teenage years.

Osler would not have known about Klinefelter’s, which was only characterised and understood in the 1950s, but Osler’s writings do have something to say about this story.

The head and the heart

As part of my preparation for this lecture, I read and re-read many of Osler’s essays. One dominant theme in his writing is the importance for doctors of the “head and the heart”. For example:

The Army Surgeon, 1894

‘an art engaging equally heart and head’

Teaching and Thinking, 1895

‘The physician needs a clear head and a kind heart; his work is arduous and complex, requiring the exercise of the very highest faculties of the mind, while constantly appealing to the emotions and finer feelings.’

The Master-Word in Medicine, 1903

‘The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.’

Ethicists have tended to focus on the importance of the ‘heart’, of compassion and kindness. In Mr T’s case, the surgeon in 1968 had his ‘heart’ in the right place since he did not want to cause the patient or his parents ‘needless worry about an untreatable condition’, but the surgeon made a dreadful mistake of the ‘head’. He mistakenly informed the GP that there was no treatment for Klinefelter’s. There was, and there is little doubt that Mr T’s life would have been radically different had he been treated then.

In Teacher and Student (1892), Osler wrote of the importance of the Quality of Thoroughness:

‘It means such a knowledge of diseases and of the emergencies of life and of the means for their alleviation, that you are safe and trustworthy guides for your fellowmen.’

That does not mean, of course, that a general surgeon should know about Klinefelter’s syndrome but that he or she should either look things up or follow Osler’s advice when he said:

I have learned since to be a better student, and to be ready to say to my fellow students “I do not know.”’

That surgical registrar in 1968 could have just told the GP that he “does not know” about the management of Klinefelter’s. That would have led the GP to refer Mr T to a specialist.

Instead, the registrar – on this occasion – failed to be a “safe and trustworthy guide” to his GP colleague, with tragic, life-long consequences for his patient.

The Hippocratic Oath

A big clue about Osler’s ethics lies in his admiration for the Hippocratic Oath. In Chauvinism in Medicine (1902), he writes of ‘the high moral ideals, expressed in that most memorable of human documents, the Hippocratic oath.’

In an unpublished lecture in 1910 on ‘The Lessons of Greek Medicine’, he called the oath the ‘credo’ of the profession.

In my role as an ethicist, I deliver one to one ethics training to doctors who have been accused or found guilty of misconduct by their employer or their regulatory body. Whatever they did wrong, whether it’s a mistake of the head or the heart, I always start the course by looking at the Hippocratic Oath, which is only about 400 words long but contains the essence of medical ethics. One passage reads:

I will not cut persons labouring under the stone but will leave this to be done by men who are practitioners of this work.’

My interpretation of this is that doctors should know the limits of their competence and refer to suitable colleagues when something falls outside their own limits. Only then can they truly benefit the ill and keep them from harm, which are other instructions in the Oath.

Interestingly, in the case of Mr T, it’s not the medic who needs to refer the patient to the surgeon but the surgeon who needs to refer to the medic!

The modern version of the Oath might read:

I will not make recommendations about treatments for conditions outside my field of expertise but will leave this to be done by men or women who are practitioners in that field.’

Speaking out

In the 1970s, 80s, 90s and 2000s, Mr T’s doctors had opportunities to tell him about the suspected diagnosis made in 1968. Several of them had spotted the letter from the surgical registrar, dated 20th Aug 1968. Yet, none of them said anything to Mr T. 

I have asked myself and others why they withheld this from him. Part of the answer must be that the doctors were reluctant to open the proverbial ‘can of worms’, especially in a 10 minute consultation. After all, they might have received a complaint or even got sued by the patient. It was much easier to maintain the status quo.

There are two helpful lessons from Osler here.

The first is his emphasis on the golden rule.  

In Chauvinism in Medicine (1902), he wrote ‘the golden rule is not always, as it should be, our code of ethics’ (emphasis added).

In Nurse and Patient (1897):

In some of us the ceaseless panorama of suffering tends to dull that fine edge of sympathy with which we started. […] we physicians and nurses have but one enduring corrective – the practice towards patients of the Golden Rule of Humanity as announced by Confucius: ‘What you do not like when done to yourself, do not do to others’

I suspect most of us, if we applied the golden rule to Mr T’s situation, would have wanted to know the truth, or at least been given the option of knowing the truth.

Now, an awareness of the Golden Rule does not mean that people will actually apply it, especially when it could lead to an awkward or unpleasant situation. This is where the second lesson from Osler comes in.  

The second lesson is the importance of moral courage, so prevalent in Aequanimitas (1889).  Referring to the ‘cares and anxieties incident to professional life’, Osler writes ‘Stand up bravely, even against the worst’ and continues ‘if the fight is for principle and justice, even when failure seems certain, where many have failed before, cling to your ideal, and, like Childe Roland before the dark tower, set the slug-horn to your lips, blow the challenge, and calmly await the conflict.’

It is not enough to think ethically, to have virtuous thoughts, but you must also act ethically and this at times will require a great deal of moral courage. I suspect some of Mr T’s doctors knew that giving Mr T the option of knowing the truth about his condition was the morally right course of action. Nonetheless, for whatever reason, they failed to act on this knowledge.

In his book Disrupted Dialogue, the American bioethicist Robert Veatch dismissed Osler’s philosophy as ‘pop-philosophy’ and more recently Fiddes and Komesaroff have called for a reappraisal of Osler’s legacy, criticising Osler for, among other things, ‘avoid[ing] the debates concerning medical ethics’.

My response is that Osler never claimed to be a philosopher, in fact quite the opposite. In Science and Immortality (1904), he wrote: 

Neither a philosopher nor the son of a philosopher, I miss the lofty vantage-ground of a prolonged training in things of the spirit enjoyed by my predecessors in this lectureship.’

Osler certainly did not avoid discussing the ethics of his profession, even though he rarely used the word ‘ethics’ in his writings. In fact, I would argue that a significant part of his work is about ethics, about the fundamentally moral nature of medicine, about that special bond between doctor and patient and between doctors themselves, about the importance of a doctor’s character, about moral ideals, the virtues of the head and heart, such as wisdom, patience, coolness of nerve, courage in the face of injustice, respect for patients and colleagues, humility, kindness and good judgement. These lessons about being a doctor and the practice of medicine, like so many of the classical texts quoted by Osler, transcend time. Surely that is why, 100 years on from his death, we still write and talk about Osler and still apply his advice to contemporary cases, like that of Mr T.

When I last saw Mr T, he had a beard. It was the first time in his life he had been able to grow any facial hair. He was also in a happy relationship.  

A few months ago, we obtained a large settlement in compensation for Mr T’s losses over the last 50 years.

Daniel Sokol is a medical ethicist and barrister at 12 King’s Bench Walk, London. He is the author of “Tough Choices: Stories from the Front Line of Medical Ethics” Book Guild, 2018). Twitter@danielsokol9

Competing interests: None declared. 

Patient consent was obtained for the content of this article.