Reviewer: Paul J. Millea, MD MA(Medical College of Wisconsin)
Description: This book is a story about the influence of medical ethics in physician practice conveyed with exceptional detail, comprehensive citations and notes.
Purpose: The author's thesis is that there has been a disaffiliation and then reaffiliation with the Western philosophical tradition by physicians over the last 200 years. Given his previous writings, I anticipated explication of the historical social and economic forces foundational to physicians' perception of their professional role and their societal position together with how these perceptions led to the cycle of disaffiliation and reaffiliation with the humanities. This account owes no intellectual debt to Nietzsche, Foucault, or Bourdieu. Rather, the argument curiously constructs a lineage of prominent Scottish, English, and North American physicians each classified according to the extent they engaged the philosophers and humanists of their day.
Audience: The book is addressed primarily to bioethics professionals and medical sociologists. The author is a credible authority.
Features: Through an impressive series of close to 400 publications spanning the past 30 years, Robert M. Veatch has commented upon virtually all aspects of practice, supplying the most social constructivist voice in contemporary bioethics. As such, opinions of his work tend to be polarized. I count myself as an admirer. The following excerpt from one of his papers will locate his thought for readers unfamiliar with his work. "The way of the future, the way of the twenty-first century, lies in the recognition that many systems of belief and value exist, each with its own ethic. Each of these ethics gives rise to a unique understanding of the proper ends of the various professions. For example, Catholic moral theology gives rise to a Catholic understanding of the goals of the medical professional role. Jewish or libertarian or Nazi ethics, in turn, generate their own understanding of the medical professional role. There are, in effect, as many medical ethics as there are underlying ethical systems. There is no such thing as an ethic intrinsic to the practice of medicine because there is no such thing an all purpose generic medicine." (Veatch RM. Modern vs. contemporary medicine: the patient-provider relation in the twenty-first century. Kennedy Institute of Ethics Journal Dec 1996;6(4):366-70) Part I characterizes the era of John Gregory of Scotland, an adherent to the school of Common Sense Moral Philosophy. From the description, one gleans that this school was an early precursor to American pragmatism whose proponents continue to be represented to this day by writers such as Richard Rorty. (Consequences of Pragmatism: Essays, 1972-1980 (University of Minnesota Press, 1982)) This is an example of one of the missed opportunities in the book. What is it about the academic environment of 1770 that compels Gregory to explore and accept a pragmatist conception of reality? Recall that American physicians of the late 19th century had William James' pragmatism available to them and yet did not use it to organize their thinking. (Some Problems of Philosophy Burkhardt FH, Bowers F, Skrupskelis IK Eds. (Harvard University Press, 1979)) Leaving Gregory, we examine Alexander Monro, Primus, the quintessential modern medical scientist (p. 23). As such, Monro is construed to compartmentalize philosophic thought from his work as a physician scientist. One available interpretation is that Monro found demonstration of at least a minimum of philosophic knowledge socially necessary, but when it came to his standing in professional circles, the moral principles by which the profession tacitly regulated itself did not necessarily include those derived from philosophic thinking. The statement that Alexander Monro, Primis, is the archetype of the modern medical scientist who has dropped out of the conversation with the humanists and has no real interest in the ethics of the profession (p.28) is baffling in light of the author's explicit acknowledgment that ethics represents the values governing professional behavior. In this sense, to have no real interest in the ethics of one's profession would correspond to professional suicide. Indeed, the author subsequently chronicles adoption of an explicit ethical code by a local medical society in Boston and subsequently by the AMA in 1847. These codes, derived from the work of Thomas Percival and Benjamin Rush, serve to regulate interpersonal relations among physicians but have little to say about physician-patient relations. One of the major concerns the AMA code of 1847 addresses is the prohibition against commerce with irregular physicians including homeopaths, Thompsonians, and others. Here the author misses an opportunity for historical scholarship. What economic and historical forces were operating that lead to the public explication of an ethical code among the allopathic physicians? What does it mean that this code is primarily concerned with business relationships between practitioners rather than relationships between physicians and patients? Why were allopathic physicians afraid of the practices of the homeopaths, Thompsonians, and osteopaths so much so that they prohibited consultation with them? Were major figures such as Samuel Hahnemann and A.T. Still marginal in regard to the discourse between medicine and the humanities? Hahnemann acknowledged an explicit debt to philosophers such as Bacon and Hume and Still led a life committed to moral action. The story the author tells of why U. S. physicians were detached from classical philosophic systems of ethics is not salient: that detachment arose possibly because of the young age of entry into medical school of students who, in contrast to Gregory, had weaker social and intellectual connections...and lesser preparation...from England or Ireland.... (pp. 37 - 40); possibly because the amount of information exploded causing physicians to replace the complete ethics of former times with the attenuated ethics of the Hippocratic Oath. The book does not consider the intellectual epoch of modernity, the Industrial Revolution, capital formation or urbanization as factors in this shift of physicians away from conventional ethics to an ethics of the capitalist jungle. Chapter 7 of Part III recounts facts from the lives of several physicians deemed potentially contradictory to the hypothesis, asserting that their engagement with ethical and philosophic ideas was superficial at best. The evidence offered seems indeterminate, as the author acknowledges at least in the case of Osler. The depiction of a lifetime of coming close to the humanities establishes Osler's considerable grasp of humanities. The pattern of delineating Osler's many accomplishments in philosophic-related arenas, namely "lifelong interest in classical figures" and then diminishing them with qualifying statements such as ... he was only a teenager ... only at an amateur level ... thirty years since he left the formal study of the humanities ... an admiring auditor ... never discussed ... (p. 128 - 130) fails to undermine Osler as an iconographic figure in the ethical practice of medicine despite the author's conclusion "if his interests had been more contemporary and more in the direction of medical ethics, he would be the one clear-cut exception...." (p. 135). In Part IV, the reasons offered for reconvergence of physicians and humanists comprise Bioethics 101: Nazi physician abuses, research abuses, transplant capability, technology to prolong life and patient activism. Unfortunately, this account is panglossian. A new day has dawned where patients engage in their own decision-making; subjects are given full informed consent before enrolling in research trials; and physicians are talking with humanists once again. Nowhere do we cover the crisis of research misconduct, the crisis of conflict of interest, the crisis of access to care, the crisis of poor training and medical error, the crisis of attending physicians pressured for more and more clinical revenue. The fundamental story of how the medicine of triumph and largess of the 50s, 60s and 70s devolved into the current medicine of scarcity and suspicion is left untold.
Assessment: This book disappoints on multiple levels. The author appears unmoored from his career of arguing for the particularity and locality of ethical systems. The book implies that for almost two centuries the medical profession operated within an ethical vacuum, a view I am sure the author does not hold. This is not to claim that such an ethics would appeal to contemporary physicians. Nonetheless, it was an ethics. The thesis that the medical profession abandoned the Western philosophic tradition as an ethical foundation because of the overwhelming body of scientific knowledge required to practice medicine remains unconvincing and uninteresting to readers like me.
