The Travails and Triumphs of Publishing the First Global History of Medical Ethics

March-April 2009

BY: ROBERT B. BAKER, Ph.D., and LAURENCE B. McCULLOUGH, Ph.D.

The Cambridge World History of Medical Ethics Examines the Evolution of Medical Ethics from the 12th Century to Today

Dr. Baker is director of the bioethics program at Union Graduate College-Mount Sinai School of Medicine and the William D. Williams Professor of Philosophy at Union College, Schenectady, N.Y., and Dr. McCullough is chairman, Medical Ethics and Health Policy at the Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston.

It's a large authoritative-looking green book with gold lettering on the cover and spine, about the size of standard piece of stationary but as thick as phone book. Weighing in at around 4 pounds, it took a team of two editors working with 56 authors from 20 countries during the course of 12 years to write the 63 chapters that fill the 876 dual-column encyclopedia-like pages that make up The Cambridge World History of Medical Ethics.

One of the first things readers will find in the book is a 77-page "Chronology of Medical Ethics." As historians, we sought to offer clinicians, bioethicists—everyone, in fact—a sense of historical context in which events occurred, texts were written and policies implemented. The Chronology, with its multi-column representation of events, people, texts and policies graphically presents this context, showing as well as telling what happened when.

We started the Chronology in 4,000 BCE, the date of the first known cities which, if you take the notion of "civilization" as the culture of cities literally, is the birth of civilization. The first three people cited in the Chronology are religious figures: Moses (circa 1,200 BCE), Kong Qiu or Confucius (551-479 BCE) and Buddha (563-482 BCE). Jesus doesn't enter the pages of history until half a millennium later. The first texts cited are those of the Hippocratic Corpus, including the oath (around 400 BCE), followed by St. Augustine's De Civitate Dei (City of God) in 413 CE, cited for its discussion of suicide. These are followed, in turn, by two pivotal Islamic texts, Hunain Ibn Ishaq's, More Questions and Answers and al-Ruhawi's The Ethos of the Doctor, both written between 850 and 899 CE. The first Asian work listed is Ishimpo, compiled in 10th century Japan by Yasuyori Tanba.

Anyone whose curiosity was piqued about Jewish, Confucian, Buddhist, Christian or Islamic medical ethics can, of course, find detailed information in various chapters of the book.

Documenting Landmarks
As the Chronology makes graphically clear, Christian medical ethics emerge in the 12th century with the development of the decretum and Ad Aures, the latter dealing with issues of doctors' guilt in cases involving medical errors. By the 14th century, physicians such as Henry of Mondeville began speaking on medical ethics and, anticipating a debate that would echo down the centuries to contemporary bioethics, humanists took pen in hand to criticize physicians and medical practices. Among these proto-bioethicists was Petrarch, who famously quipped that "physicians are the only occupational group that can kill people and go unpunished."

By the 16th century, Europeans had rediscovered Hippocratic medicine, and in 1525, the known Hippocratic texts were translated into Latin, the universal language of European medicine and science. In the same century some medical schools reintroduced the tradition of swearing the Hippocratic Oath on graduation (Heidelberg, 1558).

We constructed the Chronology so that it would offer easily accessible reference points for current events, like the upcoming worldwide celebration of the 450th anniversary of Galileo's birth in 2014. Anyone seeking to put this worldwide celebration in historical perspective by thumbing through the Chronology will find Galileo's 1633 statement to the Inquisition abjuring the "heresy … that the sun is the center of the universe … and that the Earth is not the center of the same and that it does move." "Tradition has it," the Chronology reports, "that Galileo said under his breath 'E pur si mouve!'  (but still it moves.)"

Turning pages from the 16th to the recently passed 20th century, the Chronology lays out, with all the impartiality of a calendar, the birthdates and doctrinal publications that culminated in the Holocaust and the Nuremberg Medical War Crimes Trials. The dates of three 19th-century publications foreshadow the dark turn that German medicine will take.

Before 1870, the term "euthanasia" meant what we today mean by "palliative care," a good, pain-free death. Then in 1870, an otherwise unknown school teacher, Samuel Williams, published an essay appropriating the term "euthanasia" to describe "mercy killing." In 1893, when the Johns Hopkins University medical school was founded and the Nightingale Pledge was first sworn by nursing graduates in Detroit, proponents of two radically different views of medicine were also born: Hermann Göring of Third Reich infamy and Andrew Ivy of the American Medical Association, a key witness for the prosecution at the Nuremberg Medical War Crimes Trials. In the next year, 1894, the last major medical text to use "euthanasia" in the old sense of palliative care was published.

A year later "euthanasia" is translated into German as euthanasie in Dr. Adolf Jost's book Das Recht Auf den Tod (The Right to Die). In the process Jost extended the meaning of "mercy killing" to include people whose lives are burdensome to others.

By 1905/1906, thinkers in America and Germany had taken up the cause of euthanasia, the Society for Racial Hygiene was founded in Germany, and a bill legalizing euthanasia was proposed and defeated in Ohio. In 1910, the Swedes set up a racial hygiene society. Three years later, the editor of a major German journal proposed legalizing euthanasia. In 1916, an American physician-eugenicist starred in a film about the need to "speed the death" of infants with birth defects. In 1919, a major German institute championed racial hygiene, and the next year, two German professionals, a psychiatrist and a lawyer, publish a small book arguing that those living unworthy lives be subjected to euthanasie.

In 1926, Adolf Hitler endorsed this new ideal of euthanasie, the elimination of those whose lives were not worthy of being lived, in his book Mein Kampf (My Struggle) and three years later, a major American book was published on racial hygiene.

The dates of subsequent publications and movements show Americans sympathetic to these ideas—until 1939, when the Nazi Aktion T-4 initiated a killing program that terminated the lives of more than 70,000 children whose disabilities are said to render their lives as unworthy of being lived. Gas was first used on mental patients the next year, ushering in the ultimate culmination of the Nazi racial hygiene program, which became the Holocaust … and the rest, tragically, is history.

The Chronology records the opening in 1947 of the Nuremberg Medical War Crimes Trials, followed the next year by the World Medical Association's reassertion of Hippocratic ideals in its Declaration of Geneva, alongside the UN's Universal Declaration of Human Rights. Although this seemed to clear the conscience of the medical world, two small entries for the 1960s indicate that two American and British whistleblowers, Henry Beecher and Maurice Pappworth reported major abuses of research subjects—"human guinea pigs," Pappworth calls them—in their respective countries.

In 1971, the Chronology records two Americans became the first to use the term "bioethics" for publication. The next year, Jean Heller of the Associated Press publicized whistleblower Peter Buxton's revelations about the abuse of African-American males in the Tuskegee Syphilis study. From this point forward the Chronology chronicles the internationalization of the term "bioethics." It closes in 2000, as does the book itself, recording the publication of Compendio Bioético by the pioneering Argentine physician-bioethicist José Mainetti and Japan's enactment of the Human Cloning Regulation Act.

History is about people, as well as events, policies and texts. In our effort to make the history of medical ethics readily accessible, we placed 53 biographies of major figures in the global history of medical ethics at the back of the book. In the H section of the biographies, for instance, one finds Ernst Heinrich Haeckel (1834-1919), the evolutionary biologist whose philosophy helped to shape German racial hygiene; Isaac Hays (1796-1879), the Jewish-American physician who helped to found the American Medical Association and draft its 1847 Code of Ethics, the first modern national professional code of medical ethics; André Hellegers (1926-1979), the Jesuit-trained Dutch-American obstetrician-ethicist, who founded one of the world's most important bioethics institutes, the Kennedy Institute of Ethics; Hippocrates (c. 460 BCE – C. 375-351 BCE) the ancient Greek physician to whom the Hippocratic Oath is (incorrectly) attributed; Friedrich Hoffmann (1660-1742), a German physician-ethicist whose Medicus Politicus set the stage for modern medical ethics; and Worthington Hooker (1806-1867), the Yale professor of medicine and science educator who wrote the only book on medical ethics published in America in the 19th century.

Going Deeper
Balancing the accessibility of the biography and Chronology are 62 chapters written by the world's leading bioethicists and historians of medicine that offer in-depth analyses of the global history of medical ethics from Africa to Asia to Latin America and the Middle East. The context for these histories is presented in an opening section on major cultural conceptions of the life cycle, which emphasizes that medical ethics flows, to a considerable degree, from the often quite different meanings that various cultures ascribe to transformative events that set the parameters of people's lives: conception, birth, childhood, adulthood, disease, disability, dying and death.

Some of the latest scholarship in these areas may surprise readers. For example, "Nazi medical ethics" seems like an oxymoron—how could an evil regime produce anything that could reasonably be called ethics. Yet many scholars have noted that Nazis based their medical rationale on the health of people rather than individuals, and that their notion of racial hygiene involved a war on tobacco, a campaign for organic and whole grain foods, summer camps for kids, and a predilection for vegetarianism—as well as their notorious eugenic campaign to sterilize or kill people with mental or physical disabilities. Other scholars compare Nazi medical war crimes with those that Imperial Japanese physicians committed against Chinese citizens in World War II—and with American radiation experiments conducted during the Cold War.

It may also come as surprise to some to learn that bioethics was initially an American movement led, in large measure, by Roman Catholics responding to uncorrected abuses of human research subjects. Here we quote directly from one of the chapters:

"[Researchers' reluctance to admit, apologize for, or implement new policies to curb the abuse of human research subjects] cried out for a new constellation of social controls and a new ethical paradigm strong enough to override the accepted ethos of professional competence, honor, and the research imperative. These controls and their justificatory paradigm emerged from an unlikely amalgam of bureaucrats, dissident intelligentsia, and concerned professionals. The alliance was forged in the 1960s and 1970s in the context of social ferment over civil rights, the Vietnam War, woman's rights, and other issues of social justice. A small group of intellectuals moved from protest politics to government commissions and hospital ethics committees. Marshalling these forces were two "think tanks" founded by liberal Catholic intellectuals: The Hastings Center (founded in 1969 as the Institute for Society, Ethics and the Life Sciences in Hastings-on-Hudson, New York) and the Kennedy Institute of Ethics (founded in 1971 as The Joseph and Rose Kennedy Center for the Study of Human Reproduction and Bioethics at Georgetown University). Co-founding the former was Daniel Callahan, executive editor of the lay Roman Catholic journal, Commonweal, from 1961 to 1968; founding the latter was an Edinburgh University-educated Dutch Roman Catholic scientist André Hellegers (1911–1979), nicknamed "The Pope's Biologist." America's leading Roman Catholic family provided initial funding for The Kennedy Institute.

"Like Jews and Negroes, before the Presidency of John F. Kennedy (1961–1963), Roman Catholics had been excluded from the mainstream of American social and political life. When, for example, Edmund Pellegrino (Director of the Kennedy Institute of Ethics, 1983–1988) applied to medical school 'a letter from one Ivy League school complimented … his grades but declined his application stating that he would be happier with his own kind.' Pellegrino's academic advisor told the young man that 'Italians … were no more welcome than Jews in the major medical schools, and he might fare better if he changed his name. Pellegrino refused.' … American Roman Catholics drew on their experience as a religious minority to critique the powerful in the name of the powerless—extending that critique to encompass the rights of patients and research subjects.

"Although founded and often funded by Roman Catholics, the new bioethics think tanks catalyzed a dialogue among health care professionals, lawyers, philosophers, scientists, social scientists, and theologians from a variety of religions on such subjects as abortion, contraception, population growth, genetics, new biomedical technologies, and research on human subjects. This outreach effort was partially inspired and catalyzed by the theological ferment associated with Vatican Council II (1962–65), which promoted an ecumenical dialogue between Catholics and theologians of other faiths about many subjects, including developments in biomedicine that became the substantive content of the new field of bioethics."1

Coping with Setbacks
In addition to the usual travails that beset editing a major multi-authored volume, the editors faced challenges of almost biblical proportions in bringing The Cambridge World History of Medical Ethics into print: insurrection, devastation (computer crashes), floods, sickness, madness (or to use contemporary jargon, "decompensation") and deaths. Insurrection was probably the most unusual of the challenges we faced. We ourselves are practicing bioethicists with extensive clinical experience who had trained in both philosophy and history, and we initially conceived of the volume as a collaborative effort whose chapters would be jointly written by bioethicists and historians of medicine. We were collaborating intensely even though we barely knew each other when we started the project. We described our initial relationship in the Preface:

"In 1996, we were mere acquaintances. Both of us had been active in bioethics, both of us published on the history of medical ethics, and one of us had contributed a paper to a conference and a volume edited by the other. Beyond that we were almost strangers. And so, two bespectacled, bearded, balding, middle-aged scholars of distinctly different temperaments began a mutual courtship. We found that we had both majored in some form of history as undergraduates, that we loved art and ballet, that we had a common middle name and a common taste for archival scholarship, and that we both believed, as we were to write in a grant proposal, that 'a historically uninformed, crisis-centered mind-set will rob bioethics of critical perspective, rendering its intellectual footing precarious.' On this basis we built a fertile partnership and an enduring friendship."2

Our major reason for creating this book was to make the history of medical ethics accessible to people working in clinical contexts, especially fellow bioethicists. Newer work in the history of medicine had revealed inadequacies of much of the older scholarship that bioethicists and clinicians relied upon. To get this point across, we are perhaps the first reference work to open with the words "once upon a time"—a phrasing we chose to indicate, diplomatically, the fairy-tale-like nature, the "just-so story" character of many traditional histories of medicine that offer "heroic [portrayals of]… doctors' triumphs over disease … [while ignoring] economic … gender, political, racial, religious and socio-cultural factor."3 Seeking to present the history of medicine and medical ethics from this richer, broader perspective we decided to commission historian-bioethicist teams to write various chapters of the book. We assumed, naively as it turned out, that since we delighted in interdisciplinary collaborative work, others would happily engage in it as well.

Saint Francis de Sales is usually credited with the observation that the road to hell is paved with good intentions. Our good intentions turned out to have hellacious consequences, leading to an insurrection that almost torpedoed the project when we brought the contributors together in Houston, Texas, in 2000, for an editorial conference to review chapter outlines and drafts. At opening session, in front of observers from the National Endowment for the Humanities (which had provided major funding for the project), historians of medicine began to complain loudly that they couldn't collaborate with bioethicists because they tended to focus on events, policies, and texts without any sense of context. Responding in kind, bioethicists complained that historians' intense focus on context undermined the significance of policies and texts.

Our attempts to explain that we hoped the differing perspectives would complement each other came to no avail. Then the eminent Japanese bioethicist Rihito Kimura of Waseda University (now President of Keisen University, Tokyo) began to speak softly of his own experience. "I have just come from a meeting that legalized kidney transplantation in Japan," Dr. Kimura said. "We had been [unable to legalize transplantation because we were] prisoners of our past. Everyone needs to understand their past. I think this project is very important." Someone suggested that we break into small groups and with that the real work of reviewing outlines and drafts of chapters got underway.

The incident passed but it had a lasting impact on the volume. Peruse the table of contents and it will be evident that except for two excellent chapters on the history of Japanese medical ethics that Dr. Kimura wrote with the eminent Japanese historian Shizu Sakai and a chapter on the history of legal and quasi-legal regulation of medical practitioners in the United States by the bioethicist-historian team of Steven Lathan and James Mohr, none of the other chapters were written collaboratively by bioethicists and historians of medicine.

Historians worked with fellow historians, and bioethicists with fellow bioethicists; Chinese and Japanese bioethicists even collaborated on writing history of the infamous Japanese Unit 731 that conducted bacteriological and other experiments on captured Chinese during World War II—a subject so volatile that in 2005 Japan's reluctance to apologize almost led to break in diplomatic relations with China. With these few exceptions, bioethicists and historians of medicine wrote independently of each other—although they critiqued drafts of each other's chapters.

It was not quite smooth sailing even after this: Ahead of us were disruptive and destructive computer failures, floods from Tropical Storm Allison in the Texas Medical Center that closed one editor's office building for more than four months and, later, a flash flood in Schenectady, N.Y., that turned hundreds of pages of marked-up manuscripts into a sodden moldy illegible lump at the other editor's office. Any number of ailments, physical and psychological, plagued the lives of our contributors. Three died in the course of producing the book. And then, eight years into the project Terence Moore, our editor at Cambridge University Press, died. Terry had conceived the idea for this project and invited us to direct it and edit the book.

Only someone who has led a project like this can have any sense of what is involved. We were seasoned senior scholars when Terry recruited us, with awards, books and collaborative projects to our credit, but we were really unprepared for challenges posed by a volume of this magnitude. Terry was our mentor, our guide, and when he died we were at a loss. So too, for a while, were the folks at the press. It took us all a few years to regain our bearings. Finally, the various proofs crossed our desks and, after months preparing the index and checking and rechecking the proofs, in December 2008, after 12 years, we opened the covers of The Cambridge World History of Medical Ethics.

Closing Thoughts
In the end, we believe that the volume we created in collaboration with dozens and dozens of other scholars was well worth the effort. We hope and believe The Cambridge World History of Medical Ethics will make the history of medical ethics accessible to clinicians and to fellow bioethicists, offering them both context, a reference work and in-depth analyses of the history of medical ethics and bioethics. Our initial inspiration can be summed up in the words of the great Spanish-American Catholic philosopher George Santayana:

"Progress, far from consisting in change, depends on retentiveness. When change is absolute there remains no being to improve and no direction is set for possible improvement: and when experience is not retained … infancy is perpetual. Those who cannot remember the past are condemned to repeat it."4

We created this book to help our field, bioethics/medical ethics to progress from infancy to maturity. Our contribution to this progress is to provide it with the resources to remember its past.   


NOTES

  • 1.Robert Baker, "The Discourses of Practitioners in Nineteenth- and Twentieth-Century Britain and the United States," in Robert Baker and Lawrence McCullough, eds., The Cambridge World History of Medical Ethics (New York: Cambridge University Press, 2009), 446-464.
  • 2.Baker and McCullough, p. xvii.
  • 3.Baker and McCullough, p. xv.
  • 4.George Santayana, The Life of Reason (New York: Scribner's, 1905), 285.

About the Authors

Robert B. Baker, Ph.D., is director of the Union Graduate College-Mount Sinai School of Medicine Bioethics Program and William D. Williams Professor of Philosophy at Union College in Schenectady, N.Y., where he directs the college's Rapaport Everyday Ethics Across the Curriculum initiative. A four-time National Endowment for the Humanities awardee, Baker is founding chair of the Affinity Group on the History of Medical Ethics of the American Society for Bioethics and Humanities. Recent publications include the award-winning American Medical Ethics Revolution (Johns Hopkins, 1999), and a 2007 report on African-American physicians and organized medicine. Published in the Journal of the American Medical Association, this report prompted the board of the organization to apologize publicly for past treatment of African-American physicians. Baker also co-directs a Fogarty Center of the National Institutes of Health program, which is providing online training to administrators, bioethicists and researchers in Eastern Europe and the countries of the former Soviet Union about international standards of research ethics.

Laurence B. McCullough, Ph.D., holds the Dalton Tomlin Chair in Medical Ethics and Health Policy in the Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, where he is also associate director for education. He is the author or co-author of six books, editor or co-editor of six additional books, and author or co-author of more than 350 articles in the peer-reviewed literature and 100 textbook chapters. He serves on ethics committees at St. Luke's Episcopal Hospital, Texas Children's Hospital, and the Michael E. DeBakey Veterans Affairs Medical Center, all Baylor primary affiliated hospitals. He also directs the Ethics Consultation Program at St. Luke's. He teaches Baylor medical students at the school's award-winning ethics track and clinical services for residents in medicine, obstetrics and gynecology, pediatrics and psychiatry.

Learn More about This Book
A preview of this forthcoming book published by Cambridge University Press is available at www.cambridge.org/us/catalogue. The link includes the table of contents and an excerpt from Chapter 1 titled "What is the History of Medical Ethics?"

 

Copyright © 2009 by the Catholic Health Association of the United States
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