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The first edition of The Patient as Person appeared in 1970. The book was the published form of the Lyman Beecher Lectures at Yale University, delivered by Professor Paul Ramsey of Princeton University in April 1969. Those lectures and the book that resulted from them can rightly be called the founding preaching and scriptures of the field of bioethics. Bioethics did not exist when Paul Ramsey stepped to the podium on April 14, 1969. The word itself first appeared a year later in an article by Dr. Van Rensselaer Potter entitled "Bioethics: The Science of Survival." However, the topics that Ramsey addressed in his lectures-the definition of death, care for the dying, organ transplantation, and research with human subjects-were beginning to be discussed and debated, mostly in obscure scientific gatherings but occasionally in public places, such as congressional hearing rooms. In 1962 the Ciba Foundation in Great Britain sponsored one of those obscure scientific conferences that gathered some not-so-obscure figures of science to discuss "Man and His Future." For several days, Nobel Prize winners in medicine and molecular biology, along with many leading physicians and scientists and a few (very few) humanists, reflected on the prospects for genetics, the neurosciences, and behavioral modification by drugs and surgery. The savants reached no conclusions but expressed concern that scientific progress, desirable as it might be, could lead humankind in unexpected directions, where technical achievement might outstrip moral wisdom. In 1968, in the more public setting of a congressional hearing called by Senator Walter Mondale, the social implications of advances in medicine and the biosciences were reviewed over eight days of hearings. Organ transplantation and genetic research took center stage, with prominent scientists extolling progress and occasionally, together with a few humanists, calling attention to the paradoxical consequences of many advances. Mondale and his fellow senators asked whether some form of public oversight might be advisable. With few exceptions, the scientists and physicians repudiated this idea, with Dr. Owen Wangansteen, one of the nation's senior surgeons and himself a professor at Mondale's own University of Minnesota, disdainfully saying, "If you are thinking of theologians, lawyers, philosophers and others to give some direction.... I cannot see how they could help.... The fellow who holds the apple can peel it best." So when Paul Ramsey took up the general topic of medical ethics in an era of rapid technological advances, he was addressing an audience that had heard rumors of problems. No one had yet attempted to articulate these problems in a systematic and comprehensive fashion. Ramsey, then, was not the first to speak of these questions as ethical, but he was the first to take a synoptic view.
The Lyman Beecher Lectures were a strange venue for this expression. Established in 1873 to honor a Yale graduate of 1797, the lectures had usually expounded on a theological topic, often on the work of the Christian ministry, before a Divinity School audience. In the past, distinguished speakers, usually from the ecclesiastical world, had delivered impressive lectures from the pulpit of the Divinity School chapel. The 1969 lectures, however, were jointly sponsored by Yale Divinity School and the Yale School of Medicine and were organized as never before. Professor Ramsey lectured four times in the Harkness Auditorium of the Sterling Hall of Medicine. Each lecture was followed by panels in which commentators from medicine, law, theology, philosophy, and elsewhere, responded to Ramsey's points. Also, each day, seminars were led by prominent scholars from many fields and theologians from the major denominations to expand on the issues Ramsey raised. Thus, the Beecher Lectures were transformed from a solo performance by a prominent church figure to a week of active debate across disciplinary and denominational lines. All of this was a response to a series of questions that were quite novel and unfamiliar to many of the participants.
Paul Ramsey held the post of Harrington Spear Paine Professor of Religion at Princeton University. He received his divinity degree and doctorate at Yale in the early 1940s and had been at Princeton since 1944. Having achieved preeminence in the field of Christian ethics, he wrote extensively about moral philosophy and moral theology in traditions beyond his native Protestantism. He had devoted three books to the moral problem of warfare, a topic that in the 1960s was, to put it mildly, hot. In the mid-1960s, Ramsey was frequently invited to conferences devoted to ethical quandaries in the biosciences, where he spoke cogently and somewhat acerbically about the shallowness of scientists' moral thinking about abortion and genetics. So when he arrived at Yale for the Beecher Lectures, he was not only a name in theological ethics; he was one of the few proper ethicists who had addressed these questions. The other few were Joseph Fletcher, then Professor of Moral Theology at Episcopal School of Theology in Cambridge, Massachusetts, who had enunciated liberal positions on such topics as abortion, euthanasia, and reproductive technology, and Professor James Gustafson, then Chairman of Yale's new Department of Religious Studies. Gustafson had written, just a year before Ramsey's Beecher Lectures, a comment on the growing number of conferences on moral questions in the biosciences: "Such conferences and the papers that are published from them are important at this stage of the discussion ... but one hopes we can move beyond the conference procedure to a more disciplined, careful, long range way of working in which areas of disagreement can not only be defined but in part at least overcome. What is needed, it seems to me, is interdisciplinary work within universities or centers that have personnel and resources for the arduous tasks of intensive and long-term work."
Gustafson initiated the invitation to Ramsey. He intended to use the setting of the Beecher Lectures as the beginning of the "interdisciplinary work within universities" that, in his opinion, would come to grips with these looming issues in a systematic way. Gustafson and Ramsey had a long collegial association, and Gustafson, who had himself recently become interested in the ethical questions associated with advances in bioscience, knew that Ramsey had begun to address these issues. Gustafson suggested that the staid Beecher Lectures be transformed into a week of seminars and discussions, involving participants from Yale's schools of medicine, law, and the arts, and including distinguished scholars from other institutions. He proposed that Catholic theologians and Jewish rabbis, at that time not present in the world of Ivy League scholarship, be invited to participate. Out of these ideas, a unique event emerged: interdisciplinary, interdenominational, interuniversity, designed to begin, even in temporary and transitory fashion, "the arduous tasks of intensive and long-term work" that would bring into the desultory discussions both a disciplined and principled analysis and an informed discourse.
Paul Ramsey not only presided over this unusual event, he had prepared himself for it in an unusual fashion. After receiving the invitation to present the Beecher Lectures, Ramsey determined to speak of these novel topics, not from a speculative viewpoint, but out of an experience of joining scientists and physicians as they actually confront the problems he wished to elucidate. With the cooperation of Dr. Andre Hellegers of Georgetown University School of Medicine, he approached the Joseph P. Kennedy Foundation with a request to support a year of residency as Visiting Professor of Genetic Ethics. During the spring semesters of 1968 and 1969, this Princeton theologian joined Georgetown internists, transplant surgeons, obstetricians, and geneticists on their ward rounds and in their conferences. Special conferences were arranged in which medical faculty presented cases for discussion and where Ramsey could both learn the nature of the issues in a practical way, and begin to formulate responses that reflected the mind of a scholarly theological ethicist. As he wrote in the preface to The Patient as Person, "I could put my questions to experts in many fields of medicine, overhear discussions among them, and begin to learn how teachers of medicine, researchers, and practitioners themselves understand the moral aspects of their practice."
Paul Ramsey was a scholar and a talker. As scholar, he possessed a capacious intelligence and acute analytic skills. He was widely read within and without his tradition. He wrote with eloquence, though some might say, with grandiloquence. As talker, he was articulate and, some might say, incessant. But above all, as talker, he argued. He loved to tear a thesis to tatters, puncture a careless proposition, and reveal the weaknesses in an opponent's strong points. Although some found him ruthless and intimidating, they frequently followed his line to a sharper, sounder opinion of their own. Some of his fiercest opponents became his closest friends, and many students who cringed under his criticism came away more confident. These qualifications, of scholar and argumentative talker, fit the bill for the Beecher Lecturers as Gustafson conceived them. They also inaugurated a revolution in ethical analysis.
Ramsey chose four topics for his four lectures: "Updating Death," "Caring for the Dying," "Giving and Taking Organs for Transplantation," and "Consent in Medical Experimentation." A fifth lecture, "Choosing Patients for Sparse Medical Resources," was prepared but not given, although it is included in The Patient as Person. These topics covered the ground of contentious issues in medical ethics, with the exception of issues related to reproduction and genetics. In each lecture Ramsey reviewed the current state of scientific discussion, stated the moral problems at issue, carefully dissected those issues, and made proposals for structuring a moral argument. As scholar, Ramsey moved beyond a description of the problems to the construction of a moral argument built on certain fundamental concepts and principles and following certain logically dictated steps.
Ramsey opens this project by alluding to a fundamental notion of Judeo-Christian belief: God makes a covenant with humanity, offering steadfast love and fidelity and asking in return that humans manifest to each other the care that mirrors that divine fidelity. That covenant comes to each human, constituting each one as sacred. He says, the "chief aim of [these lectures] is ... simply to explore the meaning of care, to find the actions and abstentions that come from adherence to covenant, to ask the meaning of the sanctity of life, to articulate the requirements of steadfast faithfulness to a fellow man. We shall ask, What are the moral claims upon us in crucial medical situations and human relations in which some decision must be made about how to show respect for, protect, preserve, and honor the life of fellow man?" These words appear in the preface of the published edition of the lectures. Despite an assiduous search, I have not been able to locate the actual text of the lectures as delivered, so I do not know how Ramsey introduced these fundamental ideas. The actual chapters open not with the first lecture, on defining death, but with the concluding one, on consent as a canon of loyalty in medical research. That chapter begins with a brief allusion to consent as the expression of a bond of fidelity between persons: fidelity, as Ramsey says, is "normative for all the covenants or moral bonds of life with life." However, throughout the lengthy text of each chapter, and presumably of each lecture, little more is said about covenant itself. This profound theological notion disappears into a moral analysis that is accessible to readers who might not share or understand its deep implications for human relationships. It disappears but is not gone, for the ideas of both the sacredness of each individual, specifically as individual, and that humans must not only respect that sacredness but care for each one who suffers, needs, or is threatened or diminished, sustain the moral analysis of each topic. This insistence on the sacredness of each individual repudiates the counterpoint utilitarian thesis-that individuals may be subordinated to social uses and communal purposes-which Ramsey contends has crept into medical ethics under the pressure of technological advance.
The Patient as Person exhibits the sharp mind of a thinker who has read the literature in moral philosophy and moral theology, reflected on complex methods of ethical argumentation, and applied them to real moral perplexities. In the years preceding the Beecher lectures, he had taken a step, unusual for Protestant theologians of his day, into the arcane but highly developed world of Roman Catholic moral theology. Such concepts as natural law, the principle of double effect, and the techniques of casuistry (or moral analysis in "the prism of the case," as Ramsey puts it) had been incorporated, in his own idiosyncratic way, into Ramsey's mode of moral analysis. In particular, he formulated a tightly reasoned thesis that some ethical principles were "exceptionless," that is, had an absolute status in moral argument that did not allow for any relaxation. This essay is not the place to follow Paul Ramsey's ethical theory: suffice to say that he approached medical ethics as a Christian believer with a refined concept of the way Christian belief viewed the moral life and a thesis that the central notions of Christian morality could be applied beyond the doctrinal limits to the moral life of humankind. What the Christian could understand as fidelity to God's covenant, any human open to honest moral reflection could see as canons of faithfulness between persons in need of each other. Further, Ramsey the Christian ethicist brought to medical ethics a set of finely and firmly argued principles and methods for moral analysis. As he said in the preface to The Patient as Person, "medical ethics cannot remain at the level of surface intuitions or in an impasse of conversation stoppers. At this point there can be no other resort than to ethical theory."
Using these talents, Paul Ramsey worked out the first explicit reasoning on several much-discussed questions. He prefaces his particular topics with the assertion that "medical ethics today must indeed be 'casuistry'; it must deal as competently and exhaustively as possible with the concrete features of actual moral decisions of life and death and medical care."
Excerpted from THE PATIENT AS PERSON by Paul Ramsey Copyright © 2002 by Yale University. Excerpted by permission.
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|"The Structure of an Ethical Revolution: Paul Ramsey, The Beecher Lectures, and the Birth of Bioethics"|
|"The Patient as Person: Beyond Ramsey's Beecher Lectures"|
|1||Consent as a Canon of Loyalty with Special Reference to Children in Medical Investigations||1|
|Ethics in the Consent Situation||3|
|The Ethics of Consent||5|
|Research Involving Children or Incompetents||11|
|Pro and Con||26|
|Children in Institutions||40|
|2||On Updating Procedures for Stating That a Man Has Died||59|
|The Challenge to Old-Fashioned Death||59|
|What Death Is and Telling That Death Has Occurred||63|
|The Harvard Report||89|
|On Not Confusing Death with Stopping Extraordinary Means||98|
|On Not Confusing Death with "Organ Donor Eligibility"||101|
|3||On (Only) Caring for the Dying||113|
|Ordinary and Extraordinary Means||118|
|The Morality of (Only) Caring for the Dying||124|
|The Process of Dying||132|
|Caring for the Seriously Ill and the Irreversibly Ill||136|
|The Same Objection from Two Opposite Extremes||144|
|Two Possible Qualifications of Our Duty Always to Care for the Dying||157|
|4||The Self-Giving of Vital Organs: A Case Study in Comparative Ethics||165|
|Am I My Twin Brother's Keeper?||165|
|The State of the Question in Roman Catholic Morals||175|
|Transimplantation as a Single, Uninterrupted Action||181|
|The State of the Question in a Possible Protestant Position||185|
|A Meditation on Medicine's Ministry to the Flesh||188|
|5||Giving or Taking Cadaver Organs for Transplants||198|
|6||A Caveat on Heart Transplants||216|
|In the Prism of a Far Away Case||216|
|Heart Transplants as Investigational Trials||221|
|Heart Transplants as Treatment, Elective Only||227|
|7||Choosing How to Choose: Patients and Sparse Medical Resources||239|
|Let the Better Man Live||242|
|A Human Lottery?||252|
|All Should Die When Not all Can Be Saved||259|
|How Shall Sparse Medical Resources Be Distributed Justly?||266|