Robert Baker, Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution, Oxford University Press, 2013
James C. Mohr
Department of History
University of Oregon
Eugene, OR, USA
The history of American medical ethics is a notoriously unwieldy field that encompasses an enormous amount of complex material. No single book can realistically analyze all of its dimensions in a genuinely scholarly fashion. But Robert Baker, one of the nation’s most distinguished professors in that field, has now provided the rest of us with an immensely helpful survey of one of its most important aspects: the evolution of what he terms “the formalized statements of medical morality” (164). Much of Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution traces, in an almost genealogical manner, medicine’s shifting behavioral codes and ethical systems from colonial midwifery oaths and Percival’s “ur-text” on the subject right through to the governmentally legislated standards of the contemporary period. The prodigious amount of research evident on every page of Before Bioethics helps to explain why such a book had never been written before. This is Baker’s magnum opus and it will surely become and remain a standard reference.
Baker contends that those who see the rise of meaningful medical ethics as a recent development are wrong. In his view, the American medical profession had a long history of concern about ethical standards—but those standards were necessarily products of their times. In the early Republic, for example, traditional notions of gentlemanly honor, on the one hand, and the perceived obligations of those who possessed special skills, on the other hand, combined to produce upright behavior among physicians. Transgressors could repent and rehabilitate themselves, or risk being ostracized. In such a world, the main problems facing medical organizations were internal disputes over what was or was not personally honorable, so early medical codes emphasized measures designed to mitigate internal conflicts, or “flytes” as they were called. The responsible treatment of patients—according to the generally accepted social and religious norms of that era—could be assumed among honorable practitioners. While this approach to medical ethics is regarded with skepticism by many modern Americans, Baker offers reasons to take it seriously by tying it to Charles Bosk’s (1979) “forgive and remember” analyses of medical training.
As historical circumstances changed, so did attitudes toward behavioral norms. The proliferation of diverse healers in the wide open medical marketplace of the early nineteenth century forced mainstream American physicians to articulate their own positions more systematically. The most important result, following earlier efforts at the state and local level, was the American Medical Association’s 1847 Code of Medical Ethics. By the last quarter of the nineteenth century, as organized medicine coalesced around licensing laws that generally favored AMA standards, that code attained an all but scriptural status.
Like all scriptures, however, the AMA Code was open to interpretation. In Baker’s view, the interpretations made by AMA strongman Nathan Smith Davis and his allies during that same last quarter of the nineteenth century put medical ethics tragically off its traditional evolutionary tracks. Rather than address ethical controversies at the national level, where they would have caused disruption, Davis allowed separate state and local organizations to decide for themselves how to deal with controversial questions—like whether to recognize black physicians and how to punish transgressing colleagues. The situation worsened when the infamous consultation clause of the AMA Code was interpreted by the Davis group not as an inclusive compromise designed to promote best practice but as a dogmatic absolute with which to persecute perceived heretics, among whom he included even the most educationally sophisticated homoeopaths. Baker labels Davis and his associates “Pharisees,” whose dictatorial and exclusionary rulings all but destroyed an older tradition of flexible and evolving ethical standards that would be appropriate to all physicians.
Internal revolts against Davis’s heavy-handed manipulation of the Code culminated in the AMA’s 1903 Code revisions, which paved the way, in Baker’s view, for more than half a century of unguided, laissez-faire ethics within the American medical profession. A majority of physicians seemed to prefer no ethical guidance from above to the potential for strictures they might not find convenient. As a result, physicians as a corporate group proved unable any longer to address such controversies as the appropriate professional duties during an epidemic (as in the 1918 flu or the AIDS outbreak), or professional responsibilities to legal authorities (as in questions of confidentiality in court or the sterilization of insane asylum patients), or the appropriate treatment of human subjects (as most famously in the Tuskegee syphilis study), much less what Baker calls the many “morally disruptive technologies” developed during the twentieth century. The latter included such things as the development of dialysis machines (which raised questions of who should have access to the limited number of those machines) and the invention of ventilators (which raised questions about death itself, since bodies without functioning brains could be kept “alive”).
Into medicine’s self-imposed ethical vacuum, according to Baker, swept a disparate group of outsiders claiming that they could deal with the ethical implications of disruptive technologies and research dilemmas that the medical profession had been trying unsuccessfully to finesse. Finding themselves increasingly under attack during the 1960s and 1970s both from the public (thalidomide, Tuskegee, costs) and from the government (the political battle over Medicare, antitrust suits, costs), the medical profession essentially abdicated as arbiter of its own ethical standards and tacitly agreed instead to accept the imposition of those outside answers as solutions to their ethical problems. As Baker puts it, “After a half-century adrift in the rhetoric of laissez-faire medical ethics, the AMA seemed to have lost its moral moorings. The ethical guidance that would ultimately be recognized as authoritative would come from a surprising source: a hodge-podge alliance of humanistic clinicians and scientists with lumpen intelligentsia from law, philosophy, and theology who created a new field that came to be called ‘bioethics’” (231).
If Baker is correct about the ad hoc origins of what morphed into bioethics, why did such an unsystematic admixture of self-appointed non-medical moralists develop into such a large, free-standing, and well-funded field? Baker’s answer, put succinctly, is because their approach—at least in the short run—”worked.” By inventing such concepts as “brain death” and by elevating “informed consent” to the status of an ethical absolute, the new bioethicists allowed the business of medicine to carry on—some would say wriggle off the hook—without costly internal disruption or even serious disputation. Since these new answers to ethical dilemmas in the field of medicine were coming from theoretically disinterested third parties outside the field—most of whom had some humanistic, academic, or theological imprimatur—an unquestioning public went along. The federal government quickly followed suit.
For the sake of practical convenience, all sides overlooked the fact that many of the bioethicists’ answers were rather blithely borrowed from traditional Christian (especially Roman Catholic) moral precepts and notions of democracy that stressed individual autonomy over public well-being, without much analytical reconsideration of their ethical application to contemporary circumstances. But none of the parties involved had any compelling interest in rocking what was an inherently unstable boat. Most physicians were willing to play by the new rules, whether they agreed or disagreed; health providers gained some degree of legal cover under the umbrella of sanctioned guidelines; and the public gained a sense of protection from what the bioethicists implicitly treated as a profession that could not be trusted to care for its own patients. Consequently, Baker argues, what began as a series of ad hoc opinions from disparate outside observers rapidly burgeoned into a field that now includes professorial chairs in most medical schools and review boards with varying degrees of legal competence and authority scattered throughout the nation’s hospitals and research centers. This is a truly dramatic tale, with (literally) life and death consequences.
Though clearly stated and largely persuasive, Baker’s presentation also has weaknesses. Some are minor. His publisher, for example, should have done him the service of stronger copy editing. There are many unnecessary repetitions and several references to appendices that the publisher apparently decided to omit. The early sections of the book make valuable additions to our academic knowledge of medical codes, but the level of detail is unlikely to capture the attention of readers outside the academy. It is also possible to disagree with his characterization of the stethoscope as the “morally disruptive technology” responsible for shifting medical attitudes toward abortion during the nineteenth-century. More serious, however, are two conceptual problems in Before Bioethics.
The first involves a dilemma encountered by everyone who writes about “the American medical profession”: it is very difficult to define exactly what that phrase means at any given time in American history. Near the beginning of the book, Baker states that his primary focus will be on “regularly educated” physicians (39–40). But the rest of the narrative implicitly assumes the existence of a collective “profession.” As Bruce Kimball (1992) has skillfully demonstrated, the word “profession” has functioned historically in the United States both as a rhetorical (or cultural) concept and as a variety of specific definitions. Beyond his initial statement, Baker never explains whom he considers to be members of the “American medical profession” (and hence influenced by its codes of ethics) at various historical junctures. Even the category “regularly educated physicians” would encompass a wide variety of practitioners at any given time during the nineteenth century, and he is aware that irregularly trained healers easily outnumbered regulars at least through the early decades of the Republic. Midwifery oaths are presented as forerunners of professional codes, though eighteenth-century American midwives were surely not trained in formal medical schools. Hence we are left to wonder whether Baker considers the ethical norms he is discussing to be generally applicable in some sense to everybody practicing any kind of healing at any time in United States history (which would put those few physicians paying attention to formal codes into a tiny minority), or to those people who took money for treating ailments (an occupational category), or to the members of formal medical societies (those somehow setting the tone for others), or to those who held legally binding licenses (which did not become widespread until the twentieth century), or to whom exactly? In short, the concept of a “medical profession,” needs more careful elaboration if we are to understand clearly who failed whom in this tale of ethical tragedy.
The other problem involves a dilemma alluded to at the outset of this review—no single book can cover such a vast and complicated field. We learn a great deal about the evolution of formal medical ethics from Baker’s book, but almost nothing about what impact those formally articulated ethics actually had—or did not have—on the behavior of everyday physicians of various sorts at different times. If most doctors usually did whatever they wanted to do, or did whatever they personally considered appropriate in any given situation, then formal efforts to codify specific ethical principles were little more than symbolic exercises. And even if all physicians of every stripe could somehow agree to an unambiguous code of ethical behaviors, judgments would still have to be made and most violations of that code would never become known, either to patients or to fellow practitioners. So at some point, someone will have to try to supplement Baker’s fine discussion of evolving ethical systems with an effort to find out how much difference those formal norms have actually made in American medical history writ large. But that will be—to put it mildly—a difficult job.
Finally, a word about Baker’s admirable intellectual objectivity, even bravery. He is, after all, a leading figure in the history he writes about and directs one of the most important bioethics programs in the country. He has and must continue to work closely with physicians. But Before Bioethics does not shrink from criticizing the nation’s doctors for what Baker regards as their historical failure of leadership and their professional cowardice. Baker has and must also continue to work with the nation’s now ascendant bioethicists. But Before Bioethics does not shrink from raising really important questions about the flimsy foundations of the field in which Baker now practices and the almost inadvertent basis for its contemporary authority.
James C. Mohr
Department of History
University of Oregon
Eugene, OR, USA
REFERENCES
Bosk, Charles L. 1979. Forgive and Remember: Managing Medical Failure. Chicago: University of Chicago Press.
Kimball, Bruce A. 1992. The “True Professional Ideal” in America: A History. Cambridge, MA: Blackwell.