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Home , Etiquette, Primum non nocere

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Some Personal Reflections on the “Appearance”

articolo of Today

Edmund D. Pellegrino

Virtue : Pre-history of bioethics Even though it has been considered by many as such, “” is not he pre-bioethics era of medical the “golden rule” of . The ethics and the non-western first genuinely moral precept of the Oath T sources has often been over- (right after the preamble) states that the looked. Chinese and Indian had physician must use his regimen for the “codes” of ethics for physicians – i.e., benefit of the patient and do not harm rules of conduct based in Confucianism (paraphrase). Thus in modern terms, the and in the Vedas. What is quite remark- of beneficence precedes the prin- Professore emerito di able is the cross cultural similarity of the ciple of non-maleficence. This is an im- Medicina ed Etica norms that define the good doctor. We do portant distinction. If primum non nocere is Medica, Georgetown University not know precisely how much communi- first, all we would have is what law pre- Medical Center e cation there was between East and West in scribes. The law does not require benefi- Presidente del th th President’s Council on the 4 and 5 centuries BC. I suspect there cence. This is moral minimalism. Rather, Bioethics (USA) was more than we realize today. Suffice it the Oath requires beneficence as a . to say, the ethics of Eastern cultures was Medical ethics thus goes beyond law and like that in the West, an ethics of virtue. is based in a positive, not a negative moral During the Hellenic period, competing precept. philosophical systems yielded different This is more than a pedantic distinction. of medicine and some result- Many ethicists, like Robert Veatch, tend ing differences in ethics, e.g., the differ- to reduce the physician-patient relation- ences between Platonic, Aristotelian, Epi- ship to a legal contract. They deny that curean and Stoic moral philosophies had the physician can determine what is repercussions on medical ethics. All, how- “good” for the patient 1 . The physician ever, had connections with the Hippo- must, of course, not assume that what is cratic Oath. The Oath is primarily an good for him is good for the patient. The ethical document – not as some physician’s obligation is to take into ac- claim. The Corpus does deal in several of count also what the patient is its books with professional etiquette – re- good. This may not correspond with what lationships between doctors. This distinc- the physician would want for himself. tion is important since some modern bio- Thomasma and I have treated this in our ethicists dispose of the oath as “Etiquette” papers on balancing the equa- and thus claim that it can easily be tion2. changed when social change. In late antiquity the Oath was adopted by Jewish scholars from Isaac Israeli to Mai- Studia Bioethica - vol. 1 (2008) n. 1, pp. 52-57

–––––––– 52 monides, and Muslim scholars like ers the moral questions arising from the Averroes and Avicenna. Many modern application of biological knowledge to scholars – Veatch, Baker, Porter – insist human affairs. Ethics I take to be the sys- that the Oath had little or no influence tematic, orderly, critical examination of and was always limited to a small group of questions of right and wrong, good and physicians3. This might have been true of evil in human conduct in any of its forms. observance of the Oath but not of its ac- The mother discipline is ethics – philoso- ceptance as a guide to ethical practice. In phical or theological – whether confined late antiquity and the Middle Ages, the to reason alone, or reason informed by often incorporated in Revelation. religiously inspired medical writing. The The “ethics” in bioethics is thus not medical profession in the major religious “new” – unless one wishes to follow some traditions has always demanded strong contemporary ethicists who substitute par- moral conduct. Many scholars deny this to ticular studies like literature, history, law, attenuate the influence of , and the and politics for ethics and grant them Oath on medical ethics. normative status. Others call for a “new” Thomas Aquinas does not discuss medical medical ethic meaning a ethics specifically except rarely as an ex- new of ethical norms For me bioethics is ample. What is significant for medical eth- superceding the Hippo- neither “new” nor a ics is Aquinas’ treatise on the Virtues cratic ethic and agreeing which expanded to Aristotle’s teaching of more closely with con- “discipline” per se. I the natural virtues by addition of the su- temporary mores. This is take the word etymol- pernatural virtues. The virtues in both not a “new” ethic but a ogically to mean sim- classical and medieval times strongly influ- different ethic strictly ply that branch of eth- enced the ethics of medicine at least until speaking. New problems, ics which considers the the Enlightenment. The “Christianiza- new issues, new contexts, moral questions aris- tion” of Hippocrates began in the early including biotechnology, ing from the applica- years of the medieval period when the and its growing progeny Oath was seen as congruent with being a like nanoethics, neuro- tion of biological Christian physician. ethics, enhancement, or knowledge to human The of the with regenerative medicine do affairs its emphasis on “humanism” moved not create a “new” ethics thinking to more anthropocentric con- but open up new moral venues within cerns. The Renaissance did not abandon which ethics as a discipline operates. religion but it also did not focus so exclu- It is also questionable whether one can sively on the next world as did the medie- rightly call bioethics a new “discipline” – val thinkers. Many of the early humanists i.e., an orderly, systematic body of knowl- in the Renaissance were themselves physi- edge derived by a distinctive method with cians. Pico della Mirandola’s treatise on certain rules of logic, inference, evidence, man had a wide influence4. It did focus on and/or methods of discourse. Bioethics in man and his special standing in nature and this sense is more akin to a derived disci- was one of the earlier treatises on what pline, one created by the conjunction of now would be called philosophical an- disciplines. If I am correct that bio- thropology. ethics is ethics applied to the set of ques- tions at the intersections between biology The history of bioethics and ethics then it is a derivative of two distinct disciplines namely biology and Now, we venture into the definition of ethics not a new “discipline” of its own it bioethics. I will state my opinion without introduces. debating current practices. For me bioethics I am fully aware that bioethics today is in- is neither “new” nor a “discipline” per se. I terdisciplinary and that this is one of its take the word etymologically to mean strengths. Indeed, it draws on more disci- simply that branch of ethics which consid- plines than any other field of inquiry today

53 –––––––– except perhaps philosophical anthropology. in the past, and became expressed in a par- Bioethics is, in fact, not so much a disci- ticular set of beliefs characteristic of the pline as stimulus for conversation between modern mind. disciplines with all the potentialities and This is not the place to develop this thesis dangers of such a broad based conversation. in detail or outline the relevant changes in Properly conducted, the interdisciplinary art, literature, politics, law and all other conversation can enrich bioethical dis- spheres of human existence responsible for course. Improperly conducted its product contemporary humanisms. For purposes of can be a cacophony of political dissonance. illustration, I would mention the follow- The advantages of this kind of interdisci- ing: Most basic is the cataclysmic shift plinary dialogue in the richness of phe- from theocentrism to anthropocentrism, nomena and detail about the moral life it from a human destiny in the next world entails. The intellectual problem is how to and a source of authority beyond man to maintain the richness of the whole with- human destiny limited to this world with out sacrificing the unique perspective each man or nature as a source of moral author- discipline brings to the dialogue. If we lose ity. This shift occurred along a series of in- that uniqueness then we end up with a tersecting fault lines – the recovery of man mélange in which the normative thrust of in the Renaissance; the Enlightenment ethics proper becomes lost in our fascina- project of an ethic free of religion and tion with the phenomena of the moral life. metaphysics and dependent on autono- If we do not take advantage of the knowl- mous human reason; the emergence of edge the other disciplines we lose the full- participatory democracy, the increasing ness of the moral experience which must power of man over physical nature and also be understood if the normative thrust then over his own nature in the rise of the of ethics is to be realistic and complete. physical and biological sciences, the result- This is one of the central conceptual chal- ing challenge to all sources of authority lenge of bioethics today – at least at its especially religion, and the growth of in- most fundamental level. Given the chang- dividual freedom and choice of morals as ing and changed ways we interpret litera- life “styles” not divine imperatives. ture, history, language, and philosophy or Many more forces could be listed. But all even theology, meeting this challenge is converged on the question of right and more difficult than ever. Interdisciplinarity wrong, or good and evil on what it means is not per se a conceptual virtue. Too many to be human and what a good life entails. bioethicists accept it as such uncritically, to The new “issues” were new contexts to the detriment of the normative enterprise be sure, but the ethical resources needed which is their particular enterprise. to deal with them were not new. They In my opinion the emergence – not birth were the same methods of ethical inquiry – of bioethics was the re- available to the ancients. In a way, the The new “issues” were sult of the many forces “new” ethics was a series of transforma- new contexts to be that shook American and tions back to the “old” ethics of Prota- sure, but the ethical world in the six- goras – i.e. man the measure of all things, resources needed to ties. This was a true social and ethics the product of social and cul- deal with them were revolution that is still not tural construction, as well as the ethics of completed. I would argue the Pyrrhonian skeptics, and the nihilism not new that the convergence of of the Cynics. This mixture became ex- the forces energizing this revolution pro- plosive when it came into contact with duced a perspective that was bound to al- the enormous powers of biotechnology to ter man’s perspective of himself and the shape human existence. This power was meanings and purposes of his existence. indeed new and it fostered illusions of a This was not a “new” ethics but a choice god-like humanity no longer needing a among perspectives on what it means to creation. be human. There perspectives were latent Humanae vitae does not constitute a new in human consciousness, argued on and on ethic which some hoped it would be to

–––––––– 54 permit contraception. Rather it concerns more anthropocentric, individual-choice the nature and purposes of procreation brand of ethics. Holding one’s own defini- which imply more than simple propaga- tion of right and wrong was considered a tion of the gene pool, or the satisfaction of moral entitlement. This right then became personal pleasure. Humanae vitae simply a criterion for all moral truth. The pre- updated Church teaching on procreation dictable relativism took hold and further and marriage. It did not invent a new the- undermined any notion of a universal ology more suited to contemporary pref- ethic for medicine or the physician-patient erences. relationship. Questions about brain , e.g., when Physician misbehavior, in clinical practice, death of the organism occurs, brain/body in human experimentation, in exploitation, relationships, aging, etc. involve not a new and conflicts of interest certainly fueled ethics but a continuing re-examination of the fires as the sociologists have demon- ethics as science increases our knowledge strated. But there was also the fact that the of the organism. I believe that many of view of illness had changed substantially. these questions lie not in ethics but in the Disease was no longer the “will of God”. philosophy of nature as Maritain described Rather it became an assault on the indi- it in the forties – a realm of inquiry lying vidual, an enemy to be defeated. It robbed between empirical science and metaphys- modern man of what he cherished most – ics. Much of the friction between science his freedom. Being ill meant being alien- and wisdom as Maritain put it in the ated from the world of the healthy, disad- neglect of a philosophy of nature. In its vantaged, limited in what one could do, place we now see contemporary philoso- forced to seek medical advice and to put phical biology which is another thing en- oneself in the power of another person – tirely5. This modernist philosophical biol- the physician. ogy explains man in terms of physics, Much of modern man’s dissatisfaction chemistry, and organis- with the predicament of illness and the mic complexity. It explains mind and physician understandably was the lightning morals as simply a complex “hard-wiring” rod for much of the resentment modern of the brain. man felt about the randomness, and irra- This having been said, I do not think bio- tionality of illness. The dehumanization, ethics is simply the fruit of the human depersonalization, and demeaning of the rights movement. To be sure, the Nur- sick by the impersonal forces of bureauc- emberg trials, the Holocaust and the mis- ratization, commercialization, institution- behavior of physicians raised justifiable alization and industrialization further public suspicion about the degree of trust alienated physicians and patients. The patients could put in their doctors. But dominance by the market ethics provided there was also the conviction that tradi- the coup d’etat which seems almost irreme- tional ethics had failed since patients and diable at present at least. public no longer believed in the Hippo- The patient rights movement as well as cratic ethic regarding the sanctity of life, the civil right and consumer rights move- the illicitness of , or the prohibi- ments also had their effects. They found tion against . The public was expression in a frequent resort to the law. not looking primarily for bioethicists ex- If one begins to see human relationships amine the issues rather it sought bioethi- primarily in contractual terms, one sees cists who would agree with their precon- ethics as a matter of law. Ethics is then ceived idea of right and wrong. These minimalistic and requires no altruism, or ideas were what was at stake. The eager beneficence beyond writing a good con- acceptance of a new set of specialists, who tract to eliminate trust and assure recom- opposed traditional was at the pense when injury occurs. heart of the hope for a “new ethic.” Bioethics emerged from medical ethics in Since bioethicists differed on the most dif- the mid sixties. In its origins medical eth- ficult problems the way was opened for a ics itself had pagan and non-theistic origins

55 –––––––– and was “secular.” It was given sanction ses on medical morals published by CUA by the three Abrahamic only in press. I had been schooled in the emergent late antiquity. The 500 year history of Catholic positions on organ transplanta- medical morals in the Catholic Church is tion, euthanasia, assisted , etc. But I a story of its own6. Academic medical eth- was taught to discuss them in our secular ics and the medical humanities received society in philosophic not theological their initial impetus with the US from the terms. Indeed keeping theology and phi- support of the United Presbyterian losophy in proper relationship with each Church in America (see my paper with other was part of my training by the Jesu- McElhinney on the pre-bioethics era 7 ). its and Vincentians. Magisterial teachings Bioethics as it exists today emerged under were a guide to both right and good deci- these auspices at least in part. Its concerns sions. But in the secular world only non- were with “values” and these were not theological arguments were admissible. strictly or even significantly linked to reli- Some of this explains my distance from gious values. the Humanae Vitae debate. I took HV as The paradox here is that the movement in Magisterial teaching which I could explain the mid-sixties which led to the Society to non-Catholic bioethicists. I did not try for Health and Human Values was made to establish HV as true except in philoso- by campus ministers. The later became a phical terms which were, of course, lim- special section of the Society for Health ited. I never wrote about the issue because and Human Values which nurtured many I did not consider myself a theologian. I of today’s leading “bioethicists”. Hence disagreed with the proportionalists I re- academic bioethics was a secular enterprise mained convinced that certain acts were in its earliest genesis in the ancient world. intrinsically wrong and could not be Modern bioethics was both secular and re- “saved” by circumstances, context, or ligious. consequences. This earned me a reputa- Secularism came to dominate early bio- tion among many clerics as a “conserva- ethics outside the Catholic Church when tive”. At the same time I remained persona professional philosophers non grata for many non-Catholic bioethi- Bioethics which was entered the field in the cists. So far as HV went, I felt that “Roma secular at the start late 60s and early 70s. To locuta est” settled the issue. It was consis- and more or less “neu- be sure, theologians like tent with my own beliefs. I did not con- tral” went from being Ramsey, McCormick and sider myself a qualified theologian. I was secular in a benign Gustafson were dealing fortunate enough to speak and write as a sense to what it is to- with bioethics issues from traditional Catholic yet within the milieu day, not just secular a theological perspective of secular bioethics. It seemed to me that and were prominent secular bioethicists had already made up but a-religious and voices in confronting its their minds on contraception, abortion, anti-religious, even mi- issues. But there were also and the related questions. litantly so a growing group of secu- I always spoke not as a theologian or phi- lar bioethicists who dealt losopher but as physician examining bio- with the issues philosophically and prag- medical issues from a philosophical per- matically. They may have had their own spective. For me mainstream bioethics was religious beliefs but did not introduce already secularized and the task of a them into the debates. Subliminally their Catholic was to stay in the debate, give religious beliefs undoubtedly shaped their voice to the Catholic medical moral tradi- opinions. Some were openly a-religious or tion and give a rational sense of the faith as anti-religious. consistently as possible. I was educated in Catholic morals and I was associated with the Kennedy Insti- doctrine, as well as Scholastic philosophy tute of Ethics in its earliest days. Its schol- in my college years. These were standard ars, with the exception of André Hellegers, in Catholic colleges in my youth (the late Richard McCormick and John Harvey, 30s and early 40s). I had read relevant the- were secular in their approach. Indeed, al-

–––––––– 56 though several had had theological train- ing, they functioned as philosophers not as Note theologians. Why this was so would make 1 an interesting case in itself. Later when I VEATCH RM., The Teaching of Medical Ethics, Hastings Center, 1973. (See also, Veatch, A Theory of Medical Eth- became director of the Kennedy Institute, ics) 2 I appointed Fr. Brian Hehir and Fr. John PELLEGRINO ED. - THOMASMA DC., For the patient’s Langan to expand the Catholic influence good: the restoration of beneficence in health care, Oxford University Press, New York 1988. 3 of the Institute. BAKER R. - PORTER D - PORTER R. (eds.), The codifi- I will not develop this question of why cation of medical morality, Kluwer Academic, Dordrecht 1993. bioethics was secular from the start in the 4 PICO DELLA MIRANDOLA, Oratio de hominis dignitate US. Suffice it to say that the reasons must 5 WALLACE WA., The modeling of nature: Philosophy of be sought in the larger cultural history of science and philosophy of nature in synthesis, CUA Press, Washington, DC 1996. the US: the deism of its founders, the 6 KELLY DF., The Emergence of Roman Catholic Medical Eth- separation of church and state, the social ics in North America: An Historical, Methodological, Biblio- revolution of the sixties, and the “melting graphical Study, Edwin Mellen Press, New York-Toronto pot” phenomenon to mention a few. 1979. 7 Thomas K. McElhinney and Edmund D. Pellegrino, What is interesting to me as a participant “The Institute on Human Values in Medicine: Its Role in many of the events in question is how and Influence in the Conception and of Bio- bioethics which was secular at the start and ethics” Theoretical Medicine, 22:291-317, 2001. more or less “neutral” went from being secular in a benign sense to what it is to- day, not just secular but a-religious and anti-religious, even militantly so. (I speak of the opinion makers who are now shap- ing the field.) I offer these observations to suggest some reappraisal about your idea of seculariza- tion of a field which was and remains secularized. Bioethics as I intimate earlier is now anti- as well as a-religious. Relig- iously oriented bioethicists are more or less disenfranchised in the public debate. Indeed, if an argument happens to coin- cide with religious, especially Catholic teachings, it is simply not given serious at- tention.

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