The opening pages to Pain, Pleasure, and the Greater Good read almost like an historical mystery or an ethical “whodunit,” (hint: it was the Utilitarians), capturing the reader’s attention immediately. It is certainly pleasing to encounter a work on utilitarianism that is not another dry philosophical text. Yet, ultimately, do the author’s philosophical points get lost in the rhetorical intricacies? I will return to this question at the end of the review.
In the introduction, Cathy Gere sets out her intellectual territory by discussing the notorious Tuskegee medical study, which, alongside the medical war crimes of the Third Reich, is usually seen as starting the discussion on the ethics of medical research. Insightfully, Gere points out that at stake was not a battle between good and evil, but a “conflict between two different conceptions of the good” (4). One, the greatest good for the greatest number – medical utilitarianism – and the other, informed consent. The rest of the book traces the history – and triumphs – of medical utilitarianism.
We are perhaps so used to multiple informed consent forms in our own personal medical encounters that we forget how recently these forms became an established part of medical procedures and research practices in Anglo-European medicine. Gere’s analysis serves as a useful reminder that it was only in the 1970s that the philosophical foundations for medical ethics were fully established. These are understood to be autonomy (we have the right to decide what happens to us), beneficence (essentially the costs versus benefits of research), and justice. This third pillar of justice was to ensure that research subjects were not solely drawn from vulnerable populations, and Gere points out that justice has since become assimilated into informed consent policies and procedures. Thus, autonomy is morally primary in research ethics, but beneficence – essentially (medical) utilitarianism – is a close second.
Gere recognizes that utilitarian reasoning will always ground medical research, but she argues that we must understand why “informed consent arose as a necessary corrective” (12). The right to informed consent she aims to prove in this work “is a principle explicitly formulated to trump utility considerations” (225). Gere then supplies throughout the book convincing evidence of a long history of problematic theories and troubling scientific experiments that were supposedly justified by considerations of utility. One particularly gruesome example from the late 1800s is the case of Mary Rafferty, who presented at a hospital with an ulcer so deep that part of her cerebral cortex was exposed. American physician Roberts Bartholow decided to probe her brain with a needle to see her responses, an experiment intended to gain scientific knowledge but not to treat Rafferty herself. Unsurprisingly, Rafferty was caused pain and suffering. After four days of experiments, she fell into a coma and subsequently died.
Medical utilitarianism, argues Gere, is not a moral procedural overlay on top of apparently value-neutral medical research. Rather, it is a fundamental worldview of the medical subject itself, the human animal, a subject driven by pain and pleasure, reward and punishment. And it is the history of this animal – through Gere’s account of utilitarian theory(ies) – that drives this book. This history begins in Chapter Two, which is primarily a discussion of Bentham’s utilitarianism. Gere offers a charmingly written overview of Bentham’s life and philosophy. But it is unclear – at least to this reader – the purpose of this overview. There are more insightful accounts of both the man and his theories elsewhere. But Gere’s philosophical biographies multiply, leaving the reader struggling to find the argumentative core of this central chapter for the book. We are offered biographies of Hobbes, and Locke, with a brief excursion into the lives and thought of Hutcheson, Hume, Smith, Beccaria, Hartley, and Priestly, all in only 20 pages. We then circle back to Jeremy Bentham, only to be informed of such minutiae as the street where he was born and the marital happiness of his parents.
Chapter Four examines the contributions of the next generation of British utilitarians, such as John Stuart Mill and the utilitarian psychology of Alexander Bain. In many ways, the discussion of Bain is more significant than that of Mill, as the former is often neglected in histories of philosophy and science. Bain provided a material foundation for human psychology. As Gere notes, his theory was not especially original, but it was historically important because it was grounded on the primal experiences of pleasure and pain. Chapter Five traces the history of utilitarian psychology in America, and we learn of some horrific human experiments that were performed under the guise of the search for scientific knowledge. These experiments were driven by the relief of pain or the production of pleasure; for example, Robert Heath “cured” one young man’s homosexuality by associating heterosexual sex with the pleasurable stimulation produced by electrodes implanted in his brain.
In the final chapter, we are in the closing decades of the twentieth century. This final chapter may be the most fascinating and informative of the book, because, among its elements, Gere explains how the “sovereign individual of reformist medical ethics” has mutated “from informed citizen to empowered consumer” (204). The advent of AIDS meant that thousands of people were desperate for treatment to save their lives, and they were not prepared to wait for drugs to go through lengthy FDA approved trials. AIDS activists argued that they had the right to choose for themselves to participate in experimental drug trials. Thus, the autonomous individual was now making a utilitarian argument: arguing for pain avoidance for the benefit of the many with AIDS.
Gere’s work is potentially important, adding to critiques of medical utilitarianism. However, it repeats what is essentially the Kantian-utilitarianism dichotomy without allowing for alternative perspectives or questioning the legitimacy of the dichotomy itself. Gere’s work is historiography and not intended to be a meta-ethical discussion, so perhaps this last comment is unfair. However, even taken as history of philosophy, the work is at times shaky. While the first references to the author’s own philosophical history may serve to humanize the work and draw in the reader, this particular reader grew weary of the many references to such things as reading philosophy in Christ Church Meadows in Oxford (23). Such autobiographical references seem to serve little intellectual purpose, and they sometimes strike false notes.
This latter comment may seem like a petty point, but it seems to be part of a bigger problem with this work. Unnecessary repetitions between chapters eventually make the work seem casually written, and the chapters themselves did not connect and build well one onto the other. Often there is jarring modern slang: Bentham “burned” through his formal education (86); Henry Beecher “nailed it” (47). Overall, the impression is that one is reading a series of lectures for students by the “cool” professor. We get vignettes of famous philosophers and amusing descriptions of their foibles or absent-minded antics; for example, Thomas Hobbes is anachronistically described as having “a little soul patch beneath his lower lip” (70); and Adam Smith’s The Theory of Moral Sentiments can “profitably be read as an Enlightenment version of How to Win Friends and Influence People” (83).
Writing intertwined history and philosophy is difficult. When Gere’s work is seamless, it sparkles. But too often the different elements are not interwoven carefully and the reader is left wondering what purpose the information and arguments serve. A firm copy editor should have taken this text in hand. Ultimately, I am disappointed. I wanted to like the work very much.
Catherine Villanueva Gardner
University of Massachusetts