Bioethics Forum Essay
The Balloon, the Bicycle, and Al Jonsen
Albert R. Jonsen, a pioneer of medicine and a founder of the field of medical ethics, died peacefully in his home on October 21 at 89. Even as his body began to weaken, his mind remained clear and his spirit strong. When we spoke at length about two weeks earlier, he talked about being at peace with things. He had completed his final edits to the ninth edition of Clinical Ethics and was still dictating a chronicle of his life.
From a personal standpoint, I was privileged to share his friendship and mentorship for almost 50 years. We first met in 1973, when I was a medical student. He was running a Robert Wood Johnson Program at the University of California, San Francisco and I was interested in applying. After about three hours of enchanting conversation, he gave me the best career advice I have ever received. “Don’t do it,” he said. “Finish your medical training first. If you don’t have the same credentials as the doctors, and share their world, they won’t listen.” Al had just completed a full year of attending class with the UCSF medical students and the experience was fresh in his mind. Following his advice, I found that I loved taking care of people and continue to practice internal medicine to this day. But I didn’t leave medical ethics behind.
The first two years of my practice were augmented by Al’s offer to participate in a weekly “seminar” held in a penthouse perched atop his apartment in San Francisco’s Marina district. The stated goal over those two years was to review the ethical works of Aristotle, Kant, and John Stuart Mill. Each session evolved into a lively discussion in the role of different ethical perspectives in medical care. I was the token “practitioner” and often referenced my recent clinical experiences. We knew we were on to something then, and each of us carried on in our own way. The other participants included Andrew Jameton, Bernie Lo, Barbara Koenig, Henry Perkins, Chris Cassel, and others.
Al wrote masterfully. His mind was always clear and precise. Initial edits were to remove all the adjectives. The word “too” was considered too much. He also had a zest for life, enjoying his friends, his second career at the Fromme Institute, and especially his time with Liz, his wife of 44 years, whom he adored. He could flash a mischievous grin, and his eyes twinkled when he thought. For humor, he preferred a good limerick. Of the many books he wrote, his favorite one was The Birth of Bioethics, but he often told me his best was The Abuse of Casuistry with Stephen Toulmin.
He and I stayed in touch while he taught at Washington but our relationship took on a new dimension when he returned to San Francisco, the city of his birth.
His academic and public career had been stellar. When he returned to San Francisco in 2001 he was ready for something different. My challenge to him was to see how well his ideas worked in the real world.
Some years earlier he had given a lecture at The Hastings Center describing what he called the balloon and the bicycle. I was not present at the talk, but he later described it to me (and published a version in the Hastings Center Report) with himself, as the philosopher, hoisted high above the landscape, above the fray and able to see far into the distance. The doctor, he envisioned as pedaling furiously on a bicycle, negotiating the ethical curves and potholes that suddenly appear in clinical practice. Al’s original idea was that the philosopher in the balloon would somehow be able to shout down to the bicyclist, like a navigator from above, giving him sage advice and direction.
It was a charming analogy. But my experience in the intensive care units and medical/surgical floors of San Francisco’s hospitals suggested that the philosopher may be shouting, but the doctors weren’t hearing. They often didn’t even know the sage was available. In 2003, Al agreed to leave the balloon and join me on the bicycle, riding in tandem, so to speak. We founded the Program in Medicine and Human Values at Sutter Health’s California Pacific Medical Center with the idea of fostering a closer relationship between philosophers like Al, and the doctors in the trenches of a large metropolitan medical center. Our regular presence on the hospital wards stimulated conversations that went beyond the medical indications and generated a steady flow of requests for formal ethics consultations.
Something we learned early was that an ethics consultation was not a two-dimensional box, fixed in time. Each case could be assessed in terms of the four categories discussed by Dr. Jonsen, Mark Siegler, and William J. Winslade in Clinical Ethics, but as we followed patients over the course of their illness, it became apparent that the categories–medical indications, preferences, quality of life, and contextual components–were constantly changing. These changes often affected the ethical nuances of the case. Instead of a static opinion, Dr. Jonsen and I began to see each case consultation as evolving into its own uniqueness– almost a living organism.
He promoted a method of ethics consultation that took the consultants to the bedside and often embedded them into the medical team. The goal was to help the medical professionals make the best treatment decisions in light of difficult circumstances. The role expanded to helping doctors and nurses understand the responsibilities and obligations of their profession. Additionally, our bioethicists are now helping them deal with the moral distress of their experiences.
This is not a job for a volunteer ethics committee member. Al quickly understood and endorsed the idea of a professional, well trained in the bioethical foundations of the field, but also with some clinical chops. This included a basic understanding of the medical components of the area in which they were working and, of equal importance, well-honed skills in trust-building, communication, and conflict management.
You can’t get this from a book, and so Al and I decided to begin training our own brand of embedded clinical ethicists in 2008. The program is not for beginners. Applicants must have a PhD or an equivalent terminal degree. The medical analogy would be a residency. Under Al’s guidance, the Program in Medicine and Human Values has produced eight fellows, and the need grows for more.
As we reflect on the many writings and accomplishments of Dr. Jonsen, I want to emphasize one more thing in his legacy. He showed us how to ride the bicycle, not just from the sky, but on the ground, sitting on the handlebars.
William Andereck, MD FACP, practices internal medicine in San Francisco and, with Al Jonsen, co-founded the Program in Medicine and Human Values at Sutter Health’s California Pacific Medical Center in 2003.