The following appeared in Volume 98, Number 2 (Spring, 1999) of the APA Newsletters

Where was bioethics conceived? When was it born? Who were its parents? Was it conceived in Edinburgh in the 1770s, in America in the 1970s, or was it an international movement, conceived in throws of moral passion inspired by the holocaust and born as fraternal twins in Europe and America? The authors and contributors to books reviewed offer different answers to these questions. Each is reasonable; everything depends, to quote the recently immortalized words of William Jefferson Clinton, "on what ‘is’ is." If bioethics is the philosophical critique of modern medical ethics, then Laurence McCullough is correct to claim that bioethics was conceived and born in the writings of the philosopher-physician John Gregory of Edinburgh (1724-1773)—even though it took a full two centuries for the discipline to receive its proper name. If, as Albert Jonsen (the first person ever to be denominated a "Professor of Bioethics") claims, bioethics is an interdisciplinary field focusing on "the moral dimensions...of the life sciences and health care," then it was conceived in America in the 1960s and was born in the following decade with the founding of the Hastings Center, the Kennedy Institute and the publication of the Bibliography of Bioethics, and the Encyclopedia of Bioethics. But if bioethics is neither the philosophical critique of medical morality, nor the academic field, but rather, as DeVries and Subedi suggest, a set of institutional arrangements and activities—ethics committees, institutional review boards—that presume a shared construction of "the ethical in medicine," then bioethics was conceived and born simultaneously in Europe and America. In this review article I discuss each of these conceptions seriatim, starting with McCullough’s, John Gregory’s Writings on Medical Ethics and the Philosophy of Medicine.

One remarkable feature of contemporary medicine is that while consumers do not expect empathy from their accountants, lawyers, mechanics, pharmacists, realtors or teachers, they expect it from their physicians. The notion that physicians ought properly to have an empathic relationship of sympathy and tenderness towards their patients is perhaps the Edinburgh Enlightenment’s greatest contribution to modern medicine. It is a uniquely Scottish invention and the preeminent apostle of this ideal was undoubtedly John Gregory. Despite the global influence of Gregory’s writings, they have been out of print throughout the twentieth century. McCullough has remedied this unpardonable neglect with a comprehensive scholarly edition of the two published versions of Gregory’s lectures on medical ethics, supplemented by student transcripts of these lectures and by material from Gregory’s unpublished manuscripts. The juxtaposition of these three sources of information about Gregory’s lectures is illuminating.

Consider, for example, the evolution of the first use of the expression ‘patient’s rights’ in English. In 1767 a medical student recorded Gregory as stating that: "…if the patient or his friends insist in applying [a medicine not approved by the physician] let them do so. Why not let a man die in his own way if he will?" (McCullough, Writings, p. 75). In the Observations (1770) Gregory is reported to have said that "a physician…has no right to hinder any man from going out of the world in his own way" (Writings, p. 107). Two years later, in the Lectures, which Gregory himself published, he writes that: "Every man has a right to speak where his life or his health is concerned, and every man may suggest what he thinks may tend to save the life of his friend…. If a patient is determined to try an improper or dangerous medicine, a physician should refuse his sanction, but he has no right to complain of his advice not being followed" (McCullough, Writings, p. 174). These passages reveal the first known use of the notion of "patients’ rights." They suggest that the concept evolved from the simple observation "Why not let a man die in his own way if he will?" into the formal statement that patients have rights that physicians have no right to override. In these and similar passages we can find the origins of the now familiar concepts that lie at the core of contemporary biomedical ethics. Everyone interested in the origins of these concepts should be grateful to McCullough for making Gregory’s ideas available.

In John Gregory and the Invention of Professional Medical Ethics and the Profession of Medicine, McCullough offers a comprehensive critical account of the development of Gregory’s medical ethics and philosophy of medicine contextualized in terms of Gregory’s biography and Scottish history. Like Gregory’s other recent biographer, Lisabeth Haakonssen (Medicine and Morals in the Enlightenment: John Gregory, Thomas Percival and Benjamin Rush, Editions Rodopi, Amsterdam, Atlanta GA, 1997—reviewed for the APA Newsletter, Fall 1996, pp. 90-97), McCullough reads Gregory as subscribing to the conception of the medical profession and of professional duty that was initially outlined by Francis Bacon (1561-1626) in his 1605 Latin-language essay, "The Advancement of Learning." In contrast to Haakonssen, however, McCullough argues that: (1) Gregory invented English-language medical ethics by transforming an informal tradition of lecturing medical students on medical propriety into a formal tradition; (2) invented secular medical ethics by providing a theoretical account of the norms of medical propriety in non-theological terms; (3) invented the idea of medicine as a fiduciary profession; (4) invented the idea of professional medical ethics (i.e., an ethic for medicine as a fiduciary profession); (5) invented bioethics by analyzing the norms of medical propriety in terms of a theoretical account of ethics that was grounded in philosophical theory, specifically, David Hume’s account of sympathy; and, (6) invented the idea of feminine medical ethics, an ethics of care, by making feminine virtues—humanity, sympathy, tenderness—essential qualities of the virtuous physician.

McCullough’s analysis provides compelling evidence to support the most apparently radical of his interpretive claims, (5) and (6). By contrasting Gregory’s lectures with those of his contemporaries, McCullough establishes that Gregory introduced philosophically grounded analysis into the teaching of medical morality. He also demonstrates that, although Gregory’s commitments were Baconian, his orientation towards ethics was decidedly Humean. What is perhaps McCullough’s most controversial thesis is also argued persuasively: that John Gregory self-consciously sought to construct a medical ethics around virtues traditionally considered feminine—especially the virtues of sympathy and tenderness that have since become the literary hallmarks of the morally concerned medical practitioner.

McCullough is less persuasive in establishing his four other theses. As he himself points out, the tradition of lecturing students on the moral propriety of medical practices was well established in the Baconian-oriented medical institutions, like Edinburgh and Leiden. What distinguished Gregory’s lectures from those of his contemporaries was their length, formality, philosophical sophistication, and the fact that, like most other lectures delivered at Edinburgh, they were delivered in the vernacular, i.e., in English. Thus to assess the extent of Gregory’s innovations (i.e., McCullough’s claims 1-4) one needs to compare Gregory’s lectures with Latin-language commentaries and lectures. Unfortunately research focusing on this tradition is scant. Given the dearth of scholarship in this area, it is difficult to credit anyone with "inventing" an idea—as opposed to, let us say, "translating" or "introducing" it into English. For example, McCullough credits Gregory with "inventing" secular medical ethics. Yet in Medical Ethics in the Renaissance, Georgetown University Press, 1995 (reviewed for the APA Newsletter, Fall 1996, pp. 90-97), Winfred Schleiner credits Roderici Castro Lusitani (1564-1627), a "converso" or nominally Christianized Portuguese Jew, with the invention of secular "medical ethics." Michael Ryan (1800-1841), a professor of surgery at the University of London who was the first academic anywhere to style himself a "professor of medical ethics," also reads Gregory as a follower of Castro’s. I suspect that once we develop a more mature understanding the Latin-language pre-cursors to Gregory, we will read him as translating an older tradition into English-language Scottish intellectual culture, and, in the process, developing an innovative hybrid of Renaissance and Enlightenment ideals for medicine and its morality.

One of the larger issues raised by McCullough’s reading of Gregory is whether the ideal of a medical profession envisioned by Gregory became the form of professional medical ethics that we recognize today. Gregory believed in the gentleman physician. He held that "the confinement of the study and practice of physic, entirely to a class of men who live by it as a profession, is unfavourable to the progress of the art" (Gregory, Writings, p. 117, quoted at McCullough, p. 246). The profession of medicine today, however, consists entirely of a class of men and women who confine themselves to its study and practice, and who attempt to make their livelihood thereby. Our professionals are thus the very professionals whom Gregory feared. McCullough concludes "Gregory infuses his concept of medicine as a profession and the physician as a gentleman with the romantic, medieval, conservative, moral-aristocratic ideal of the moral life of service in which interest never corrupts duty. [But this] concept of duty and service cuts against the grain of modern, egalitarian societies." [286] I agree with McCullough. But I take my agreement to signify that, while Gregory may have invented an ideal of the medical profession and an ethic to govern that profession, the profession of medicine that evolved in the Western democracies differs significantly from the ideal envisioned by Gregory.

Albert Jonsen’s The Birth of Bioethics offers readers a well-written comprehensive and detailed chronicle of the rise of bioethics, tracing it from tentative beginnings in a few casual conversations, through its first public steps in conferences, to its formal institutionalization in centers and institutes. Jonsen also catalogues the issues addressed in these early conferences, which evolved into the subject matter of bioethics. The volume is structured accordingly. Part One focuses on individuals and offers representative biographies of theologians and philosophers who became "bioethicists." It also offers remarkably detailed accounts of the activities of the governmental commissions on which these individuals served—transforming some of them from lawyers, philosophers and theologians into "bioethicists." Part Two focuses on the substantive issues before these commissions, which eventually became the subject matter of the new field of "bioethics"—death and dying, ethical issues in genetic research, human subjects research, new reproductive technologies, organ transplantation. In Part Three, Jonsen moves beyond chronicle—the record of who did what, when and where—to the intriguing questions of why bioethics was conceived, why the movement took the form of ethics, and why it was born in America.

Jonsen is an engaging personality who once compared a book he was reviewing to a sandwich: solid meat surrounded by uninteresting white bread. To adopt his metaphor, the Birth of Bioethics is an inverse sandwich. To me, the chronicle of the evolving subject matter of bioethics in Part II tasted like "plain white bread." But it is surrounded by the substantial and tasty biographical material in Part One, spiced up with a flavorful analysis of the role of conferences in the birth of bioethics, and by Part Three, "Discipline, Discourse and Ethics," which is just as meaty. Jonsen observes that bioethics was canonized as a discipline in 1973, when the Library of Congress recognized it as such on the basis of an article by Daniel Callahan. He clarifies this claim with an important and innovative distinction between bioethics as a discipline—a specialized field supported and recognized as such by academic institutions—and bioethics as a discourse, a widely-accepted way of discussing ethical issues in bio-medicine. Having distinguished the discipline from the discourse, Jonsen queries whether a field that lacks any settled and distinctive methodology can properly be called a "discipline." In the end he concludes that bioethics is a "demi-discipline," thereby skirting the question: how did the 1,500 individuals who belong to the American Society of Bioethics and Humanities, who work in over 200 bioethics centers and institutes, and whose 3,200 articles and books are indexed by the Bibliography of Bioethics annually come to denominate themselves as "bioethicists"—rather than as philosophers, lawyers and theologians? Jonsen also offers no clear answer to the intriguing and related question: how did they convince the rest of the world to accept them as ‘bioethicists’, with all the claims of expertise that the ‘ist’ suffix implies?

Jonsen’s explorations of bioethics as discourse are perceptive. He observes that bioethicists were remarkably successful in challenging the "techno-speak" of medical and scientific savants and in deriding the tradition of "doctor knows best" as "paternalism." They rephrased technical questions in the accessible language of patients’ "rights" (pace Gregory) and of the physician-patient "partnership." In the process, bioethical discourse became the dominant language that public and professionals alike used to discuss moral issues in biomedical science and practice. Bioethical discourse was integrated into the medical curriculum through required lectures; it was introduced into the corridors of the clinic by ethics committees and clinical ethicists; and it was disseminated to the public as the media turned to bioethicists for comments on the issues and scandals of the moment.

In explaining the triumph of bioethics as discourse, Jonsen turns to the work of three historians: Daniel Fox, Stanley Reiser (Medicine and the Reign of Technology, Cambridge, 1978), and David Rothman (Strangers at the Bedside: How Law and Bioethics Transformed Medical Decision Making, Basic Books, 1991). All three trace the birth of bioethics to the problems of exponentially expanded, publicly funded, technologically driven biomedicine run as a private fiefdom by a professional elite who deemed themselves accountable only to themselves. This elite was unresponsive to the concerns of patients and the public. As a matter of reciprocity and self-defense, therefore, patients and the public supported the creation of a new discipline, bioethics, whose mission statement was to hold the biomedical elite accountable to the values and interests of patients’ and the public. As Jonsen perceptively observes, however, none of these accounts explain why patients and the public responded by turning to ethics, rather than law.

The reason for the ethical turn, Jonsen theorizes, is that since the recruits for the new discipline were liberal intelligentsia energized by the civil rights and anti-war movements, they naturally transported the moralizing language of these movements into the clinic. (As one bioethicist remarked, "I moved easily from civil rights to patients’ rights.") The American public, in turn, was responsive to a discourse of ethical critique because of an entrenched moralizing tradition inherited from the Puritan past, because American liberalism is melioristic and reformist, rather than revolutionary, and because individualism lies at the core of the American moral tradition.

As a preliminary to writing The Birth of Bioethics, Jonsen held a conference on "The Birth of Bioethics" in Seattle in 1992. He invited "many of the pioneers of bioethics" to attend and, as he observes in the Acknowledgements, "their stories about the origins of the field...[serve] as the building blocks of this book." The book opens with Jonsen’s autobiographical account of his own transformation from Jesuit priest to bioethicist and often reads like an autobiography of a field, written by its founders, with Jonsen acting as anamneus. It will serve as the indispensable first word for all future accounts of the birth of bioethics.

In the last chapter of The Birth of Bioethics, Jonsen remarks that "the story of bioethics" as he has "told [it] is largely an American one...of course, bioethics does not exist only in the United States…And yet, in Dan Callahan’s words, ‘Bioethics is a native grown American product, which did emerge elsewhere but finds uniquely fertile ground in the U.S. " (Jonsen, p. 377).

In one of the many perceptive essays in Raymond DeVries and Janardan Subedi’s intriguing collection of essays, Bioethics and Society: Constructing the Ethical Enterprise, Dutch bioethicist Rob Houtepen offers an account of the evolution of Dutch bioethics that implicitly undercuts claims to the uniquely American origins of bioethics. Houtepen traces the birth of Dutch bioethics to the failure of traditional medical ethics to respond to the challenges of Dutch physicians and patients who were turning to euthanasia. There are remarkable parallels between the Houtepen’s analysis of the Dutch experience and Jonsen’s account of the American experience: the failure of traditional medical ethics to respond to problems vexing the profession; the turn to interdisciplinary expertise; recourse to panels and commissions; broadening the conversation to include a wider public, and finally resolution of the problems in terms of a new language that broadens the parameters of professional discourse.

Bioethics and Society is an intriguing collection of essays by sociologists and bioethicists seeking alternative models for understanding "the bioethical construction of the ethical enterprise." I found Bette-Jane Criger’s taxonomy of bioethical discussions especially illuminating. Other insightful essays were Paul Root Wolpe’s "the Triumph of Autonomy in America Bioethics: A Sociological View"; Charles Bosk and Joel Frader’s "Institutional Ethics Committees: Sociological Oxymoron, Empirical Black Box," and Jonathan Moreno and Valerie Hurt’s careful historical analysis of "How the Atomic Energy Commission Discovered ‘Informed Consent.’" Interspersed are programmatic essays denouncing analytic bioethics for its individualistic bias, or offering remarkably ahistoric accounts of such events as the debate over confidentiality during in the death of President James Garfield (1881). Despite a few uneven chapters, the book provides an illuminating alternative to current constructions of bioethics and is well worth reading.

All of the volumes under review make a significant contribution to the literature. McCullough’s contributions are especially important to those of us teaching bioethics in philosophy departments. They underscore that biomedical ethics has always been an integral component of modern moral philosophy. Our understanding of medical morality, and of David Hume, are enhanced when we appreciate that television’s exemplars of the caring clinician, Doctors Carter, Green and their ancestor, Marcus Welby display the Humean feminine virtues disseminated by Gregory. Our understanding of ourselves is also enhanced by Al Jonsen’s wonderfully perceptive account of bioethics as a discourse, and by the challenges that DeVries, Subedi and their colleagues offer to the received interpretation of bioethics. Every institution that takes biomedical ethics seriously should have these volumes on its shelves.