Albert R. Jonsen, who brought the field of bioethics to the bedside and whose way of reasoning influenced generations of medical ethicists, died on Oct. 21 at his home in San Francisco. He was 89.
Dr. William Andereck, his personal physician and a colleague, said Dr. Jonsen had been in poor health but had preferred that the cause of his death not be made public.
Dr. Jonsen was almost legendary among bioethicists, respected for his wisdom and vast knowledge. “He was a sage,” said Dr. Joseph Fins, chief of the division of medical ethics at Weill Cornell Medical College in New York.
Dr. Fins recalled a dinner with Dr. Jonsen at a restaurant on Manhattan’s Upper East Side. The conversation, he said, proceeded like “a reverse Socratic dialogue.” Instead of the professor asking students a question, Dr. Fins and others at the table would ask Dr. Jonsen a question. He would provide an answer, which would provoke the next question.
“There was no bottom to that well of knowledge,” Dr. Fins said.
Dr. Jonsen’s field, bioethics, is concerned with helping medical professionals, patients and families make difficult decisions on topics like the right to die and informed consent. It also weighs in on policy choices involving matters like the use of children or prisoners in medical research.
Dr. Jonsen was a distinguished academic for most of his career — president of the University of San Francisco, where he taught philosophy and theology; chief of the division of medical ethics at the University of California, San Francisco; and chairman of the department of medical history and ethics at the University of Washington. But that path took an abrupt turn when he accepted a challenge from Dr. Andereck “to see how well his ideas worked in the real world,” as Dr. Andereck put it.
Dr. Jonsen had endorsed four principles of bioethics: autonomy — allowing patients to make informed choices; beneficence — enabling health care professionals to make decisions that benefit the patient; non-maleficence — avoiding causing harm that outweighs any benefits of treatment; and respect for patients and their families.
In a lecture Dr. Jonsen once compared the bioethicist to a balloonist floating high above the earth and able to see what lies ahead. Below him on the ground is a frantically pedaling bicyclist — the doctor — “negotiating the ethical curves and potholes that suddenly appear in clinical practice,” Dr. Andereck said.
“Al’s original idea,” he added, “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.”
In 2003, having known him for 30 years, Dr. Andereck suggested, in effect, that Dr. Jonsen come down from the balloon and climb on the bicycle — to see how well his ideas would work in the intensive-care and surgical wards of San Francisco’s hospitals.
“He and I would start seeing real cases,” Dr. Andereck said. “He would see what happened when he gave advice and doctors said, ‘Thank you, Dr. Jonsen, but no.’”
All too often, Dr. Andereck told Dr. Jonsen, doctors either weren’t listening to bioethicists or did not even know they were there.
Dr. Jonsen’s bedside method used a form of reasoning called casuistry, which he had learned in his training to be a Jesuit priest. (He later left the priesthood.) The idea, similar to legal reasoning, is that when an ethicist is confronted with a difficult decision, resolution can come by looking at other cases like it and seeing how they were resolved.
For example, doctors and nurses often agonize over what to do when they are caring for a patient who is clearly not going to recover but is being kept alive with multiple high-tech support systems because the family refuses to let the patient go. The doctors and nurses may come to feel that they are brutalizing the patient, letting him or her live on for another week or so but at the cost of constant pain.
Dr. Jonsen would begin by gathering all the relevant facts — the prognosis, the benefit of continued treatment and the burdens on the patient. Then he would ask the family what was known about the patient’s wishes and preferences and their worries about quality of life. He would look at similar cases and how they had been resolved. His goal was to organize the facts and clarify the obligations so that the family and medical professionals could all agree on how to proceed.
His real-world experiences with Dr. Andereck led Dr. Jonsen to promote a new idea in ethics consultation: placing the ethicist at the bedside as a part of the medical team.
He and Dr. Andereck went on to establish a clinical ethics consultation service as part of Sutter Health, a large Northern California network of hospitals and clinics. The service provides more than 700 ethics consultations a year to doctors, patients and their families.
Dr. Jonsen’s many passions extended far beyond bioethics. As a philanthropist he donated money to social causes, ecological foundations, academic institutions and the Society of Jesus, the Jesuit order. He spoke seven languages, liked to sketch, immersed himself in opera and baroque music, and traveled widely.
As his nephew William Carrick said in an interview, “I often wanted to ask him if there was a list of countries he hadn’t been to.”
Albert Rupert Jonsen was born in San Francisco on April 4, 1931. His father, also named Albert, was an advertising executive with the Hearst newspapers. His mother, Helen (Sweigert) Jonsen, was the daughter of San Franciscans who had arrived in the city before the Gold Rush of the mid-19th-century.
After high school, Dr. Jonsen studied for the Jesuit priesthood and was ordained in 1962. He received a doctorate in religious studies from Yale University in 1967 and taught philosophy and theology at the University of San Francisco, a Jesuit institution, before being named its president in 1969.
He left the priesthood in 1976 to marry Mary Elizabeth Carolan.
In 1974, President Gerald R. Ford appointed him to the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, which was formed in response to disclosures in 1972 that for more than 40 years hundreds of poor Black men with syphilis in Alabama had deliberately been left untreated — and not informed of their condition — as part of government research known as the Tuskegee Study.
As part of a 1979 report, the commission recommended the broad adoption of principles of medical ethics in government research, including stipulations for informed consent by research subjects.
President Jimmy Carter subsequently appointed Dr. Jonsen to another medical bioethics commission, which called for expanding the principle of informed consent to include all patients.
The Institute of Medicine, National Academy of Sciences, elected Dr. Jonsen a member in 1981. He chaired the department of medical history and ethics at the University of Washington School of Medicine from 1987 to 2003.
Dr. Jonsen co-wrote a number of influential books on ethics, including “Abuse of Casuistry. A History of Moral Reasoning” (1986), with the British philosopher Stephen Toulmin; and “Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine” (1982), with the bioethicists Dr. Mark Siegler and William Winslade. That book is in its eighth edition and has been translated into seven languages.
Dr. Jonsen is survived by his wife; his brothers, Robert and Richard; and a sister, Anne Marie Carrick.
Dr. Jonsen, who left little to chance, wrote his own obituary before he died.
“Having everything arranged ahead of his passing is consistent with his being organized and conscientious,” Dr. Andereck said.
He noted that as “a philosophical man,” Dr. Jonsen was not afraid of death. “He contemplated it and was really quite prepared in every respect,” Dr. Andereck added. He said death had come “without a struggle.”
“His goal for a good death was to land the plane softly,” he said, “and he nailed it.”
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