Bioethics Forum Essay
Fox, Bosk, and Rothman: An Appreciation of Three Scholars of Medicine
With all of the tumult surrounding the coronavirus and the upcoming presidential election, few people likely noticed that three important figures in bioethics, medical history, and medical sociology recently died within a month of one another. But for those of us who work in these fields, the deaths of Renée Fox, Charles Bosk, and David Rothman were a major loss.
Why was the work of these three scholars so important? All three—with PhD and not MD degrees—did their finest research during a period of profound change in medicine. As early as the 1950s but certainly by the 1980s, it was abundantly clear that physicians could no longer “rule the roost,” single-handedly dictating how patients should be treated and research conducted. Those of us studying bioethics and medical history during the 1980s and 1990s made an obligatory passage through the work of Fox, Bosk, and Rothman, learning why, to use Rothman’s phrase, there were now “strangers at the bedside,” monitoring and even overruling decisions previously made exclusively by doctors.
This essay cannot begin to comprehensively describe the contributions made by these three scholars. But I will touch on certain aspects of their research. This work influenced a generation of professors who teach bioethics and medical history in medical schools and other graduate schools; it lives on in the students who have taken their courses and—hopefully—continue to bring these insights into the worlds of clinical medicine and scientific research.
Renée Fox was a medical sociologist who conducted traditional participant-observation research. But, as sociologist Robert Zussman recently pointed out to me, she—in contrast to most medical sociologists of the era—focused more on doctors as opposed to patients. Fox’s first major work, Experiment Perilous, published in 1959, explored the work of physicians who ran a research ward for chronically ill patients at Boston’s Peter Bent Brigham Hospital. Although the patients had agreed to receive experimental medications and procedures, Fox noted how this simultaneous role as both patient and subject potentially exposed them to harmful interventions. Similarly, because they were performing experiments on their own patients, the physician-investigators had a conflict of interest.
Nevertheless, Fox, who spent most of her career at the University of Pennsylvania, could not help but admire aspects of this type of research. Her next major book, The Courage to Fail, written with Judith Swazey and published in 1974, took a deep dive into the emerging worlds of hemodialysis and organ transplantation. Here Fox and Swazey found daring surgeons brimming with optimism who were developing potentially lifesaving procedures. But this bravado came at a price—often the deaths of early experimental subjects.
I love to ask my medical and undergraduate students to contemplate the term “the courage to fail” in light of the enormous successes that eventually ensued in organ transplantation. Were the early deaths somehow justified by the later saved lives? Who should decide? How do we confront similar dilemmas today? Ultimately, Fox and Swazey became disillusioned with the rescue mindset, in part due to their research on the implantation of the world’s first artificial heart in Barney Clark at the University of Utah Medical Center in 1982. They concluded that the operation, which led to several months of misery for Clark, had been “fundamentally unethical” and “profoundly disquieting,” driven by the zeal of the investigators and the Mormon background of many of the participants.
Like Fox, sociologist Charles Bosk also struggled with his assessment of physicians and his discomfort at what he observed. As a graduate student in the 1970s, Bosk was a participant-observer in the department of surgery at the University of Chicago. His most interesting findings, which appeared in his 1979 book Forgive and Remember, involved how the senior surgeons dealt with medical errors committed by doctors-in-training . Bosk attended morbidity and mortality conferences in which these mistakes, which at times caused deaths, were discussed. He found that certain technical and judgment errors were tolerated, as long as the resident physicians learned from them and did not repeat them. Other errors, however, involving moral transgressions, were unacceptable. Bosk witnessed and documented the ritualistic ways in which errors were processed, which not infrequently involved senior surgeons yelling at junior surgeons.
When I teach the topic of medical errors, I often begin with the image of a young Bosk sitting in a lecture hall witnessing what had previously been a closed-door interaction. I point out that the department’s decision to permit his research indicated to some degree they were not embarrassed by what they were doing. But, just as Fox’s work placed a pair of critical outside eyes on physician-researchers, Bosk’s did the same for surgeons. Indeed, Forgive and Remember is often credited as the book that launched the effort to reform how medicine deals with its mistakes. We now stress a “systems approach,” which downplays the blaming of specific individuals in favor of efforts to ascertain where “the system” broke down and thus enabled an error to occur.
Yet to Bosk’s credit, during his subsequent career as Fox’s colleague at Penn, he remained skeptical of looking only at systemic breakdowns, which he believed focused too narrowly on technological fixes such as computer alerts and checklists. Rather, one still had to examine the human dimensions of medical mistakes and empower health care workers to both identify them and speak openly about their ramifications.
Both Fox and Bosk were two of the strangers at the bedside that Rothman identified in his 1991 book of the same name. So was Rothman. Trained as an American historian and an expert on mental hospitals, he turned his attention in the 1980s to clinical medicine and human subjects research. Rothman was not afraid to criticize the medical profession, particularly physicians who earned money from problematic relationships with industry and those who overlooked existing informed consent practices in their zeal to do research. But Rothman, like Fox and Bosk, was no doctor-basher. From his perch at the Columbia College of Physicians and Surgeons, he loved to go on rounds with physicians and observe firsthand how they made difficult ethical decisions about death and dying and the best use of technology.
An essay I routinely teach is Rothman’s 2000 New England Journal of Medicine article “Medical Professionalism: Focusing on the Real Issues,” in which he entreats doctors to cut their industry ties, spend time providing free medical care, and become politically active. It was quintessential Rothman: a provocatively titled article in which a PhD dared to tell MDs how to do their jobs—but because he thought they could do better.
One of the joys of historical scholarship is how historians eventually themselves become part of the history. Like the people they studied, these three scholars worked at a particular historical time—one in which patient autonomy was supplanting the traditional paternalism of medical practice. Bioethics, a field with which all three had a productive but uneasy relationship, was becoming an established part of the world of medicine. By reminding us that medicine is profoundly a social process, Fox, Bosk, and Rothman helped to explain why these changes occurred. So while their work will necessarily become more dated over time, I hope that they remain on syllabi for medical, graduate, and undergraduate students. They all taught us doctors why we do what we do.
Barron H. Lerner, MD, PhD, a professor of medicine and population health in the Division of Medical Ethics at New York University Langone Health, is the author of The Good Doctor: A Father, a Son and the Evolution of Medical Ethics. He is a Hastings Center fellow. Twitter: @barronlerner
Excellent account of a great loss. Fox was my teacher. (She was on my doctoral exam committee and we retained great admination for each other while we sometimes fought over the relative contributions of sociology and philosophy to medical ethics.) Bosk and Rothman were colleagues at the Hastings Center. What a loss for three such interesting and challenging figures to go at the same time. Thanks for the moving tribute.
You’re welcome, Bob. I recall David citing your work often during my days at Columbia.
Barron, thanks for a wonderful set of tributes. One friendly amendment in response to your comment, “When I teach the topic of medical errors, I often begin with the image of a young Bosk sitting in a lecture hall witnessing what had previously been a closed-door interaction. I point out that the department’s decision to permit his research indicated to some degree they were not embarrassed by what they were doing.” I think it is important to add to the historical record that the decision was not a “department’s decision” but rather that of David B. Skinner, a thoracic surgeon who was chair of surgery at the University of Chicago. Dr. Skinner subsequently came to New York City as President of The New York Hospital-Cornell Medical Center where he was central to the establishment of our ethics committee and academic programs. He was deeply influenced by his U of Chicago friend and colleague, Mark Siegler, and a proponent of medical ethics.