In reading this chapter you will
- ►Identify the historical roots of contemporary bioethics in the development of Western medicine and its professional ethics.
- ►Recognize descriptive and normative senses of morality.
- ►Distinguish philosophical studies of morality from those of the sciences.
- ►Place bioethics in the landscape of ethics.
This chapter introduces bioethics as a practice and an area of ethics of interest to several disciplines. It does so by first looking at an early landmark case where protecting public health infringed on an individual liberty to refuse vaccination. Until the 1970s, such conflicts were resolved by appeal to accepted practice and professional codes. After briefly reviewing the history of these, the chapter looks closely at bioethics today, outlining its main branches and relations to other areas of ethics.
The advantages of vaccination policies to prevent outbreaks of infectious disease are now widely acknowledged. Yet vaccination has not always been smooth sledding. In 1758 the American Calvinist theologian Jonathan Edwards died of a smallpox inoculation shortly after his inauguration as president of what is today Princeton University. Such casualties were not uncommon when vaccinations were first introduced. The eventual eradication of smallpox and the significant progress that has been made in reducing the threat of other serious diseases, such as polio and measles, are however among the global, public-health successes of vaccination. In the US, the moral and legal grounds of vaccination mandates by the state came to be questioned most forcefully when a smallpox epidemic spread through the Northeast in 1901, causing 773 documented cases and 97 deaths. The following year Cambridge, Massachusetts reported 2,314 infected individuals, of whom 284 died. Citing an existing statute, the city’s board of health decided to enforce vaccination against smallpox for all residents, and stipulated a five-dollar fine for those who failed to comply. Among the delinquents was the Reverend Henning Jacobson, who refused the vaccine for himself and his son. He had a previous adverse reaction to it and, more important, thought the ordinance violated his right to care for his own body in the way he thought best.
The city responded by requesting payment of the fine, which prompted Jacobson to initiate legal action. The court decided that, under the police power of the state, the city’s ordinance did not violate any liberty rights guaranteed by the Fourteenth Amendment. Jacobson then appealed to the US Supreme Court, which in 1905 found for the state, emphasizing the Commonwealth’s power to enact and enforce laws aimed at protecting the public from communicable diseases.
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This was the first ruling by the US Supreme Court concerning the scope of state power in public health law. More than a century later, vaccination continues to present moral and legal challenges worldwide. In 2009, 5-year-old Edgar Hernandez
, soon to be known as ‘patient zero,’ returned from school one day with symptoms consistent with ‘swine flu’ (the H1N1-virus infection). The virus was not to remain in his remote Mexican village. A month later, it afflicted some 1,000 individuals in all parts of the United States. By June, there were 18,000 reported cases. Five months later, the Food and Drug Administration approved the use of H1N1 vaccines, and roughly 61 million Americans were vaccinated within the first three months. Faced with a short supply of the new vaccine, the State of New York’s Department of Public Health sought to protect hospital patients, who generally have greater vulnerability to infectious disease, by imposing vaccination mandates for health care providers. It considered the mandate justified by precedent from state court rulings in previous cases of mandatory rubella vaccination and annual tuberculosis testing of health care providers. The New York Times
reported that three nurses obtained the mandate’s suspension by questioning the vaccine’s proven effectiveness.1
They thus won a legal battle but not the moral war. For as health care providers, they faced a moral conflict: on the one hand, they had the duty to promote their patients’ health; on the other, the exercise of that duty interfered with their individual liberty interest to refuse vaccination or any other medical treatment. In Jacobson v Massachusetts, the Supreme Court emphasized that many liberty interests must be limited in pursuit of the common good because “a community has the right to protect itself against an epidemic of disease which threatens the safety of its members.”
Controversies over vaccination mandates may result from differing beliefs about the facts, the law, religion, or morality. Rev. Jacobson questioned the facts—namely, whether
- Unvaccinated individuals put the public at an increased risk of contracting smallpox.
- The state had the power to enforce vaccination ordinances.
- The epidemic would spread according to natural, rather than, Divine plans.
But his deepest disagreement with the court concerned the right thing to do, from the moral perspective, when protecting public health infringes on a person’s liberties. Questions of this sort pertain to bioethics, a practice and a field of academic inquiry with roots in the development of Western medicine and the professional codes of health providers.
The patient’s right to refuse medical treatment, including vaccination, was generally ignored until the rise of contemporary bioethics in the 1960s and 1970s. But long before that there were concerns in medicine about other matters of moral right and wrong, especially in connection with patient welfare. From the very beginnings of Western medicine in 5th-century Greece, physicians sought to regulate their practice by moral rules. Those who embraced the teachings of Hippocrates of Kos (ca. 460–370 BCE) hoped their rules would be adopted by other physicians. In this way, persons of defective character—including quacks and dishonest schemers of all kinds—might find the calling of medicine too morally rigorous for their taste and be driven away. The rules of Hippocratic medicine became background assumptions that persisted through more than 20 centuries until the rise of contemporary bioethics. They chiefly concern duties and decorum. Among other things, Hippocratic doctors pledged to avoid harming their patients, to keep confidential the things revealed to them in the course of treatment, and to ask as a fee no more than what the patient could reasonably afford to pay. But they were also expected to cultivate certain traits of character or virtues. Physicians should have a demeanor of seriousness, scholarliness, dignity, and reserve. They were to be scrupulously honest and polite with their patients, striving always to bring credit to their profession and to put the patient at ease. In addition, they were to regard the practice of medicine as a ‘holy’ calling, and hold their mentors in great reverence.
It is striking how many of these ideals persist even today in the mystique of medicine that undoubtedly contributes to its high social status. And although some Hippocratic duties such as what appears to be a strict prohibition of both abortion and euthanasia are controversial today, others continue to carry weight in contemporary bioethics. These include that patients have an obligation to cooperate with their health care providers, and that physicians have a duty to relieve suffering and should neither try to apply curative treatment where no cure is possible nor attempt to save from death a patient who cannot be saved.
The Influence of Christianity and Maimonides
Over the centuries, a number of other ethical rules have taken hold in the practice of medicine. Some of these originated in the late Roman period and early Middle Ages owing in part to the influence of Christianity, such as the duty of medical professionals not to abandon their patients. St. Basil of Cappadocia, probably inspired by Jesus’ teaching that one must care for the sick, founded the first hospital at Caesarea in 372, where nuns and monks served as health care providers. Hospitals on this model soon began to spring up all over Christendom. At the same time, the Hippocratic tradition took on a new moral imperative for physicians: the duty to care for the sick, putting the patient’s interest first, even when they risked exposure to deadly disease. Later, during the high Middle Ages, this duty came to be interpreted in Italian commercial cities as a duty of health care providers not to abandon patients, even in a time of plague, without regard to risk to themselves. Not surprisingly, the compliance with this new medical duty was uneven. Some were able to muster the courage to act on it, but many did not. For nurses, such a stringent duty of care had long been taken for granted, a fact evident later in Florence Nightingale’s criticism of medical professionals who care more about themselves than about their patients.
In the medieval period, however, the moral influences on Western medical ethics came not only from Christianity. Jewish scholars also made substantial contributions. Chief among them was the physician and philosopher Maimonides (1135–1204). His voluminous writings as a Talmudic scholar touch occasionally on ethics in medicine such as the duties to care for the sick and wounded and to preserve human life whenever possible. So important was the latter duty, Maimonides thought, that religious duties—even Sabbath observance—could be suspended, if necessary, to comply with it.
Another medieval thinker with influential views on the ethics of medicine was Thomas Aquinas (1225–1274), the Italian Catholic theologian and philosopher whose writings are the foundations of what’s now called ‘Thomism.’ Thomism sanctions an iron-clad duty of health care professionals to protect and extend human life whenever possible. In reasoning about this weightiest of moral matters, Thomists think that the intention with which an action is taken is important in assessing whether the action is morally right or wrong—something consistent with the common intuition that, for instance, an amputation, normally forbidden on moral grounds as mutilation, would be right when necessary to remove a gangrenous limb, thereby saving a life.
Thomism also refined casuistry
, a method for deciding what to do or believe, morally, about any given case that’s now preferred by some bioethicists over an alternative method that invokes general principles. Casuist decisionmaking begins by identifying the morally relevant facts of a case, drawing moral conclusions by comparing it with similar cases that have been already decided. We consider both methods in Chapter 3
. For now, note that Thomist bioethics continues to be a force today.
Percival’s Medical Ethics
Some new developments occurred at the very beginning of the 19th century. In 1803 an English doctor, Thomas Percival (1740–1804) of Manchester, introduced the expression ‘medical ethics’ in an influential book with that title. It was a large-scale treatise dealing with doctors’ duties in four areas: hospitals, the law, the professional conduct of physicians in private practice, and relations with pharmacists. Physicians have those duties because they are trusted to act in the best interests of the patient. Their good reputation depends on such public trust, which must never be betrayed. It is earned through an uncompromising devotion to the patient’s welfare, high scientific standards, and the benefit physicians bring to society. Doctors must also respect their patients, the poor and obscure no less than the wealthy and prominent. But they are also paternalistic toward them: the physician determines what’s in the patients’ best interests, and makes treatment decisions accordingly. We return to paternalism
in Chapter 3
Percival followed the Hippocratic tradition, not only in assuming paternalism, but also in rejecting strict veracity as a duty of physicians toward patients. A physician may deceive patients whenever she thinks that not to know the truth is in their best interest. But his contemporary, John Gregory (1724–1773), a respected Scottish physician and professor at Edinburgh, took just the opposite view, and over the next century and a half he was joined by three eminent American medical school professors who wrote on ethical questions in medicine, Benjamin Rush (1746–1813), Worthington Hooker (1806–1867...