Physician Exemplar of Faith and Reason: Robert D. Orr, MD, CM

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No observer of the state of healthcare today can deny that a sea change has occurred within our medical subculture. In the world of “providers” (practitioners, technicians, and subspecialists) Dr. Robert D. Orr stood out as a Physician, and one of integrity. That is to say, he was a fully integrated individual—theologically, philosophically, professionally, and personally—who engaged each patient and colleague with recognition of their own integrity.

This article presents a perspective on the Vermont years of Dr. Orr’s career, written as one mentored by him in the field of clinical ethics. Although he was my senior by more than a decade, our lives had run a very parallel course from the beginning. Both of us were born and raised in rural upstate New York along the Canadian border, a land of apple orchards and dairy farms. Both were highly committed to the Christian faith. Both were partially trained under the auspices of the United States Navy, each achieving the rank of Lieutenant Commander. Both were vocationally dedicated to excellence in patient care, he as a physician and ethicist, I as a nurse initially, an anesthetist secondarily, and an ethicist subsequently. Both had an initial career stint in Vermont and returned later to hold staff positions at Fletcher Allen Health Care (FAHC) now known as University of Vermont Medical Center (UVMMC) and faculty positions at the University of Vermont Medical College, now called the Robert Larner, MD College of Medicine at the University of Vermont.

Returning to Vermont in 1987 from the Graduate Hospital of the University of Pennsylvania to join the Department of Anesthesia, in 2000 I began graduate studies in Bioethics at Trinity International University (TIU) affiliated with The Center for Bioethics & Human Dignity (CBHD). It was there that a connection to Dr. Orr came about. Professor of Bioethics at TIU and Chair of the Advisory Board at CBHD, he had accepted the position of Chair of Clinical Ethics at FAHC and Professor of Family Medicine at the UVM Medical College.

Dr. David Schiedermayer, who taught my first Clinical Ethics course at TIU, insisted that the students become active in their own locale in various clinical ethics committees, institutional review boards, etc. Knowing that I was affiliated with the University of Vermont and that Dr. Orr had recently left his position at Loma Linda University in California to take the lead position in Clinical Ethics at FAHC, he encouraged me to seek Dr. Orr out.

So, it was shortly thereafter, one day during a lull in the surgical schedule, that I called Dr. Orr to request entrée into the Clinical Ethics Service at FAHC. That day, I met one of the most gracious and gentlemanly physicians of my career. He immediately invited me to his office to get acquainted. That first introduction was a course in ethics itself. Dr. Orr introduced me to what he was already accomplishing in a very short time, based on his experience as the Chair of Clinical Ethics at Loma Linda University, and invited my participation.

Dr. Orr had established a very vibrant, professionally diverse Clinical Ethics Committee. He had published notices throughout the medical center advising anyone who had an ethical concern or question regarding the care and treatment of any patient to contact the Clinical Ethicist “on call” for a consultation. Consultations were handled promptly and thoroughly under Dr. Orr’s guidance and brought before the committee for review. The committee review process served as both a safeguard and an instructional opportunity.

Dr. Orr mentored us in the four foundational principles of medical ethics (autonomy, beneficence, non-maleficence, and justice) handed down in the tradition of the Hippocratic corpus as published by Beauchamp and Childress in their text Principles of Biomedical Ethics. With some of us he shared his own publications. He schooled us in the Socratic method as to how to appropriately word the questions that need to be answered in an ethical analysis.

Dr. Orr also promulgated a notebook full of case studies from his experiences in clinical ethics as a training tool. He would host meetings after hours for the group of staff members interested in learning more regarding the field of clinical ethics. Additionally, he brought to FAHC a detailed POLST (Physician Orders for Life Sustaining Treatment) form that outlined the process and discussion involved in determining what interventions each patient accepted or rejected in the face of a life-threatening emergency. Each document had a suspension clause that could be invoked under special circumstances (during surgery, for example) with the patient’s prior informed consent.

He taught us the proper usage of advance directives and the fact that the most important factor for each patient would be the choice of candidate for the role of durable power of attorney for healthcare. I have never known anyone to be more thorough, principled, and meticulous in their approach to clinical ethics as well as the teaching thereof.

Of course, Dr. Orr’s reputation as a Family Practice physician had preceded him from his earlier 18 years of medical practice in Brattleboro, VT. Although a small and out of the way community, even by Vermont standards, he was so well known for his attentiveness to his patients, including the practice of making house calls and establishing the first area hospice center, that he earned the award of Vermont Family Doctor of the Year in 1989.

Dr. Orr was a strong proponent of physician professionalism. He thought it critically important for physicians, via their state medical board, to actively monitor and regulate their own profession. During his tenure in Vermont, there came about a case at a rural access hospital of a physician who had administered a paralyzing agent to an ICU patient whom he had been unable to wean from a ventilator. The family and he had agreed not to continue sustaining her on the ventilator, but whenever extubation was attempted, regardless of massive doses of benzodiazepine given, she would become tremendously agitated. The administration of a paralyzing agent did not prevent her traumatic agitation, but it did ensure her death without that agitation being evident to those around her.

This situation was a matter of grave ethical violation; however, physician colleagues were loathe to invoke disciplinary measures against the perpetrator, preferring to leave that role to the judicial system. The principles of the Hippocratic corpus would underwrite Dr. Orr’s proposed approach.

Dr. Orr, the public servant, was intensively engaged in promoting the cause of life in Vermont for decades.[1] Dr. Orr was involved in the initial establishment of a statewide, loosely configured group started as “Voice of the Unborn” in 1974, which became a charter Chapter of the National Right to Life Committee.

In 1976, the very first bill in favor of physician-assisted suicide (PAS) was introduced in the Vermont legislature. It was soundly opposed and defeated yet later resurfaced in 1996, and efforts to pass went full bore in 2000. In response to the increasing pressure to pass legislation legalizing physician-assisted death (PAD), Dr. Orr co-founded the Vermont Alliance for Ethical Health Care (VAEHC) in 2003 to specifically oppose legislative efforts to involve the medical profession in imposing a death sentence as part of healthcare.

Opposition to PAS/PAD remained successful for the next decade, and Dr. Orr was a tireless advocate in that effort. He appeared before the legislature numerous times to offer his expert testimony and encouraged participation in opposing such legislation by his colleagues. Eventually, however, under the administration of Governor Peter Shumlin (2011–2017), there was intense pressure from the governor’s office upon the legislative members to support the PAD initiative. The bill was passed in 2013. Interestingly, there was not a single patient request in the entire state for a full two years thereafter, demonstrating this had nothing to do with a grassroots demand for the “service.”

Robert Orr, MD: physician, professor, advisor, counselor, author, and public servant. What can account for such attentiveness, drive, and devotion? Dr Orr was a vocational physician for whom medical professionalism was “baked in” to every aspect of his career. There can be no other explanation for his level of commitment to his patients, colleagues, professional cadre, and the public good and the tireless application of his gifts to all.

Of course, there had to be an environment that could nurture such mature development of his natural gifts and tendencies. I contend it had to do with his professional formation in what I call the 3^rd Epoch of Western Medicine, which was the golden age of medicine from my perspective.

The 1^st Epoch and the 2^nd are identified in the following quote from anthropologist Margaret Mead, who defines the dividing line between the first two Epochs with the institution of applied principles of reason known as the Hippocratic corpus to the practice of medicine. She wrote:

For the first time in our tradition there was complete separation between killing and curing. Throughout the primitive world the doctor and the sorcerer tended to be the same person. He with the power to kill had power to cure . . . . He who had the power to cure would necessarily also be able to kill.

With the Greeks, the distinction was made clear. One profession . . . [was] to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect, the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child . . . but society always is attempting to make the physician into a killer—to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient.[2]

The 3^rd Epoch, the one to which Dr. Robert Orr belonged, was marked by the Christocentric developments that ensued in the wake of the Gospel teachings as described in Mike Aquilina’s book The Healing Imperative.[3] Healing arts became holistic in approach under the model and teaching of Christ. With him, healing came to mean a remedy of the unity of body, mind, soul, and spirit. It was with that model that he sent forth the 70 disciples to heal bodies but also to remedy the malady of souls with evangelization. The outgrowth of this movement was that, with the development of monasteries, the charism of hospitality was added to the formula. Thus, we get the word hospital. With the development of the hospital several advantages came about. The hospital provided the basis for a community of caring, continuity of care, evaluation, comparison of various modes of treatment (the first medical research), and having more resources at hand than the itinerant could carry along in a kit bag. So it was for centuries that both Hippocratic medicine and Christianity, in very complementary roles, served humanity well.

Enter the current 4^th Epoch. In the 20^th century Hippocrates and Christ were set aside in large part by modernity. This was not done out of the development of any superior ethic, philosophy, or theology that proved more beneficial to humanity. It was done through the imposition of ideological challenges by which the self-acclaimed intelligentsia manipulated legislatures, courts, education, media, etc. By 1980, one university in the nation still used the covenant of the Hippocratic Oath in its medical college graduation ceremony. Compounding the ethical gap between tradition and modernity, medical finances are focused on procedural and technological endeavors, leaving soul and spirit to often languish. I would contend herein lies the root of the spiraling mental illness, suicide, and addiction rates, as well as the cultural view in medicine that the imposition of death can be included among the goals of medical care.

Dr. Robert Orr did all he could to stand in the gap and stave off the consequences of the sea change that has transitioned our culture into this 4^th Epoch, one where trust and hope have been replaced in large part with anxiety and despair. It is not impossible for future physicians to follow in the footsteps of Dr. Orr, but it has become increasingly difficult.

It has been speculated that some of the health challenges Dr. Orr faced in the 21^st century were related to his unwavering commitments as a physician of faith and reason. It may be so, but it can never be doubted that in many selfless ways he would each day patiently, calmly, and with great equanimity take up his cross and follow his Lord.

References

[1] For the content in this section on Dr. Orr’s public engagement I must give attribution to Mary Hahn Beerworth, the Executive Director of The Vermont Right to Life Committee.

[2] Margaret Mead, quoted in Nigel M. de S. Cameron, The New Medicine: Life and Death After Hippocrates (Bioethics Press, 2001), 7.

[3] Mike Aquilina, The Healing Imperative: The Earl Church and the Invention of Medicine as We Know It (Emmaus Road, 2017).

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