Private Practice: In the Early Twentieth-Century Medical Office of Dr. Richard Cabot (review)

Most American physicians know about Richard Cabot (1868–1939) from the New England Journal of Medicine, which reminds its readers weekly that he started the Clinical Pathological Conference (CPC) in 1900. Chris Crenner's Private Practice does much more than fill in the details of Cabot's remarkable biography: it is an exemplary piece of scholarship, using Cabot's clinical records and patient correspondence to illuminate a much larger world of clinical medicine at a pivotal moment of change that he both catalyzed and exemplified.

Cabot and his patients were suspended between home and hospital. Cabot combined private practice with (Harvard) medical teaching and writing on diverse medical issues. While he built his academic reputation as a technical expert in the meaning and use of diagnostic technologies, the arc of his career was toward medical ethics. He became well known for his blunt attacks on placebo use and lying about terminal diagnoses.

Cabot's CPC made error in medicine too publicly visible for many of his medical contemporaries. His critics did not deny the reality of error so much as they feared that its public acknowledgment might undermine the authority of scientific medicine. Cabot believed that the more-technology-based medical practice that he promoted widened the gaps between doctor and patient; he argued that greater honesty in diagnosis and decision making were necessary to narrow these gaps and retain patient trust.

Crenner uses Cabot's correspondence with patients and colleagues to question the accuracy and importance of many aspects of the received history of modern bioethics, which has emphasized the recent emergence of the active medical consumer and informed consent, the ascendancy of greater truthfulness in diagnosis and prognosis, and the pivotal role played by bioethicists in these developments. Crenner instead portrays a more complex and nuanced past: Cabot's patients were anything but passive, deploying multiple strategies in their decision making and self-understanding. They often shopped around for the best doctors and treatments, and they implicitly exchanged respect for physician competence and authority in return for physician steadfastness and commitment to maintain hope.

Crenner uses the differences between Cabot's public pronouncements on truth telling and placebo use and his actual clinical practices to capture the complex mix of change and continuity in doctor-patient relations. Particularly revealing were two episodes in Cabot's life: his "mercy killing" of his brother, who was suffering from end-stage diabetes mellitus in the preinsulin era, and the management of his own wife's death. Cabot kept his role in his brother's death secret until nearly the end of his life. In one sense, this secrecy was conventional, for euthanasia was common but was not discussed publicly; on the other hand, Cabot found the experience extremely painful, at the time and decades later, and could not easily fit it into any explicit ethical system. Cabot's care for his wife during her terminal illness was more shockingly at odds with his public statements: he had diagnosed her as suffering from lung cancer on clinical grounds, and he took great pains to conceal from her both this diagnosis and the reality of her imminent death.

In both of these instances, the gap between private action and public pronouncement suggests how untidy and complex clinical decisions were and are, while evoking the historically contingent factors generally missing from bioethical analysis. For example, the gap becomes more understandable in light of the importance placed on familial rather than individual responsibility for decision making in Cabot's time. He and his contemporaries knew they were dealing with significant "collateral damage" from the new style of practice. Crenner devotes a chapter to Cabot's and others' changing strategies toward the great numbers of patients who could not be reliably diagnosed with objective disease. Another set of problems followed from the reality that these physicians promoted the technology-laden style of practice before there...