Table Of ContentDisrupted Dialogue
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Disrupted
Dialogue
Medical Ethics and
the Collapse of
Physician-Humanist
Communication
(1770-1980)
ROBERT M. VEATCH
Professor of Medical Ethics
Kennedy Institute of Ethics
Georgetown University
Washington, D.C.
OXFORD
UNIVERSITY PRESS
2005
OXPORD
UNIVERSITY PRESS
Oxford New York
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Nairobi Sao Paulo Shanghai Taipei Tokyo Toronto
Copyright © 2005 by Oxford University Press, Inc.
Published by Oxford University Press, Inc.
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http://www.oup.com
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.
Library of Congress Cataloging-in-Publication Data
Veatch, Robert M.
Disrupted dialogue : medical ethics and the collapse of physician-humanist
communication (1770-1980) / Robert M. Veatch.
p. ; cm. Includes bibliographical references and index.
ISBN 0-19-516976-X
1. Medical ethics—England—History. 2. Medical ethics—Scotland—History. 3. Medical
ethics—United States—History. 4. Humanistic ethics—England—History. 5. Humanistic
ethics—Scotland—History. 6. Humanistic ethics—United States—History. 7. Physicians—
Professional ethics—England. 8. Physicians—Professional ethics—Scotland. 9. Physicians—
Professional ethics—United States. I. Title.
[DNLM: 1. Ethics, Medical—history—England. 2. Ethics, Medical—history—Scotland.
3. Ethics, Medical—history—United States. 4. Humanism—England. 5. Humanism—Scotland.
6. Humanism—United States. 7. Physicians—England. 8. Physicians—Scotland.
9. Physicians—United States. W 50 V394da 2004]
R724.V414 2004
174.2'0941—dc22 2004050098
9 8 7 6 5 4 3 21
Printed in the United States of America
on acid-free paper
For Ann
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Preface
I first conceived this book over a decade ago. The intense conversation of the past
generation between humanists and physicians interested in ethics gave the appear-
ance of something new. It was not the same old professionally articulated ethics
of physician groups that had existed within medical professional associations for
the past century. It was a true interdisciplinary conversation.
Exploring further back in the history of medical ethics, I discovered that, in
another time and another place, physicians and humanists interested in ethics were
also actively engaged with one another. As the research developed, I formulated
and tested the hypothesis that the more isolated professional physician ethics in
the English-speaking world of almost the past two centuries followed an earlier
period of rich and close engagement among some of the leading humanists and
physicians of the day. That period of engagement traces back to the 1770s and
the Scottish Enlightenment, particularly in and around the University of Edinburgh.
Soon after the end of the eighteenth century, however, something happened. The
conversation stopped, and physicians became isolated, left to do their professional
ethics on their own without the benefit of active engagement in the ethical de-
bates in philosophy and religious ethics. Humanists retreated to do their ethics
work without the benefit of those on the firing lines of clinical decision making.
That earlier, more engaged medical ethics had its foundation in the general
religious and secular ethical controversies of the broader culture. Whether in the
vn
viii Preface
period of the ancient Hippocratic Oath, with its underlying Pythagorean and other
Greek philosophical roots, or the common-sense empiricist tradition of the Scot-
tish enlightenment, medical ethics at its best was an offshoot of important intel-
lectual debates having nothing directly to do with medicine. My claim is that,
beginning about 1800, the conversation that had fed medical ethics as a branch of
important philosophical and religious debate ended, and physicians were left to
work out their ethics on their own. Unfortunately, this occurred just when physi-
cians ceased to receive a broad classical education that would prepare them to work
at a sophisticated level on an ethic for their profession. Without the benefit of
knowledge of the contemporary philosophical controversies of their day, physi-
cians were reduced to reliance on simple slogans and to copying from their pre-
decessors, who had written more sophisticated ethics for medical professionals.
Those slogans and copies fit the philosophical conversations of an earlier era, but
often were out of place in the philosophical climate decades later. The dialogue
between humanists and physicians was interrupted until some 170 years had passed
(that is, until about 1970), when it rather suddenly resumed in a major and dy-
namic way, giving rise to a new and more fitting ethic for a postmodern era of
liberal political philosophy.
I will argue that during the late eighteenth century, the Age of Enlightenment,
educated physicians were in rather close communication with humanists of the
day. Professional physician ethics1 was not developed as a separate entity in that
period. Consequently, the Hippocratic Oath and the moral tradition surrounding
it did not play a central role in the thought of late eighteenth century physicians.
For some reason, however, physicians stopped talking to their colleagues in the
humanities—at least about matters of medical ethics.
Is my impression correct and, if so, why did this happen? Before this volume is
complete, we will need to explore the underlying culture and how it changed during
these two centuries. We will examine the shifts in the scientific questions believed
important for physicians to address, the changes in socioeconomic circumstances
that influenced who chose to become physicians, and the social milieu that first
forced physicians and humanists apart and then forced them back into the same
conversation.
Let me suggest an initial typology—two ways of thinking about medical eth-
ics. I will give them names for ease of reference. Think of these as ideal types. No
one person is a pure case of either type. In no historical period was there a total
manifestation of one or the other. These ways of thinking merely describe ten-
dencies or patterns. In due course, I will try to show how cultural developments
of the period account for these two patterns.
Some think of medical ethics as essentially the product of the profession of
medicine. They tend to see the Hippocratic ethic as an all-purpose, timeless epitome
of the proper ethic for the practice of medicine. I am going to call this the "Monro"
approach to medical ethics and will explain why later. Others think of medical
Preface ix
ethics as more closely associated with the broader underlying ethical milieu of a
culture. For them, there are as many medical ethics as there are general ethics.
This view derives the ethic for medicine from the general culture, not from the
medical profession itself.
According to the latter view, every system of beliefs and values includes a gen-
eral ethic from which an ethic for medicine can be derived. Talmudic ethics, for
example, yields Talmudic medical ethics. Catholic moral theology yields Catho-
lic medical ethics. Buddhist, Hindu, Confucian, and Marxist ethics yield their
respective ethics for medicine. The ethic of liberal political philosophy is the most
conspicuous and most important source of modern, secular medical ethics. Liber-
tarianism, even Nazism, has implications for a medical ethic. This might imply
ethical relativism—the notion that ethics are grounded merely in the beliefs and
opinions of cultures. It need not require relativism, however. Those who hold these
cultural views often believe that their view is the one universally correct position.
Roman Catholic theologians, for example, believe that they are attempting to ar-
ticulate the one correct, universal morality. Secular, liberal philosophers are not
much different. They are trying to develop an ethical theory that they think is
universal. Others have simply made an error. If these cultural views strive to be
universal, they imply that there is really only one universally correct medical ethic,
which is derived from the one universally correct system of ethical beliefs and
values. For our purposes, it is not critical whether holders of this second view
believe their religious or cultural tradition is the only correct one or whether they
are more relativist. What is important is that they assume that an ethic for medi-
cine is connected with and derives from a broader, more fundamental cultural or
philosophical ethic.
Holders of this second view about the relation of medical ethics to the surround-
ing culture may see the Hippocratic ethic as one among competing systems of
ethical thought derived from an underlying Greek mystery cult. Ludwig Edelstein
(1967) tells us that it was probably Pythagorean in origin.2
Some who have refined this position, including Carrick (1985) and Temkin
(1991), have said the Hippocratic ethic gained ascendency because it was com-
patible with early Christian ethical views. For example, the prohibition on abor-
tion and condemnation of euthanasia were compatible with Christian views.
However, Carol Mason Spicer and I have argued that the Hippocratic Oath is a
manifestation of a peculiar ancient Greek mystery religion that was in many im-
portant ways at odds with the ethics of ancient Jewish and Christian culture (Veatch
and Mason, 1987).
I shall call this second view, which sees medical ethics as derived from under-
lying cultural ethics, the "Gregory" view. Although the names I give these views,
"Monro" and "Gregory," refer to individuals, I use them to refer to a much broader
cultural phenomenon—whether the ethics of physicians is isolated from a broader
cultural ethic (the Monro view) or an integrated part of that broader ethic (the
