Robert B. Baker

A Draft Model Aggregated Code of Ethics for Bioethicists

Bioethicists function in an environment in which their peers—healthcare executives, lawyers, nurses, physicians—assert the integrity of their fields through codes of professional ethics. Is it time for bioethics to assert its integrity by developing a code of ethics? Answering in the affirmative, this paper lays out a case by reviewing the historical nature and function of professional codes of ethics. Arguing that professional codes are aggregative enterprises growing in response to a fields historical experiences, it asserts that bioethics now needs to assert its integrity and independence and has already developed a body of formal statements that could be aggregated to create a comprehensive code of ethics for bioethics. A Draft Model Aggregated Code of Ethics for Bioethicists is offered in the hope that analysis and criticism of this draft code will promote further discussion of the nature and content of a code of ethics for bioethicists. 1. This paper was originally presented at Union College on April 9, 2005 at the Ethics of Bioethics Spring Meeting of the American Society of Bioethics and Humanities, co-sponsored by the Albany Medical College and Graduate College of Union University Centers for Bioethics, and held in Albany and Schenectady, New York, April 7–9, 2005. A fuller version of the history examined in this article will be found in two forthcoming papers by the author, “A History of Codes of Ethics for bioethicists,” and “Codifying the Ethics of Bioethics.”

African American Physicians and Organized Medicine, 1846-1968: Origins of a Racial Divide

Like the nation as a whole, organized medicine in the United States carries a legacy of racial bias and segregation that should be understood and acknowledged. For more than 100 years, many state and local medical societies openly discriminated against black physicians, barring them from membership and from professional support and advancement. The American Medical Association was early and persistent in countenancing this racial segregation. Several key historical episodes demonstrate that many of the decisions and practices that established and maintained medical professional segregation were challenged by black and white physicians, both within and outside organized medicine. The effects of this history have been far reaching for the medical profession and, in particular, the legacy of segregation, bias, and exclusion continues to adversely affect African American physicians and the patients they serve.

The Cambridge world history of medical ethics

Part I. An Introduction to the History of Medical Ethics Part II. A Chronology of Medical Ethics Robert Baker and Laurence McCullough Part III. Discourses of Medical Ethics Through the Life Cycle Part IV. Discourses of Religion on Medical Ethics Part V. The Discourses of Philosophy on Medical Ethics Part VI. The Discourses of Practitioners on Medical Ethics Part VII. The Discourses of Bioethics Part VIII. Discourses on Medical Ethics and Society.

Creating a Segregated Medical Profession: African American Physicians and Organized Medicine, 1846-1910

An independent panel of experts, convened by the American Medical Association (AMA) Institute for Ethics, analyzed the roots of the racial divide within American medical organizations. In this, the first of a 2-part report, we describe 2 watershed moments that helped institutionalize the racial divide. The first occurred in the 1870s, when 2 medical societies from Washington, DC, sent rival delegations to the AMAs national meetings: an all-white delegation from a medical society that the US courts and Congress had formally censured for discriminating against black physicians; and an integrated delegation from a medical society led by physicians from Howard University. Through parliamentary maneuvers and variable enforcement of credentialing standards, the integrated delegation was twice excluded from the AMAs meetings, while the all-white societys delegations were admitted. AMA leaders then voted to devolve the power to select delegates to state societies, thereby accepting segregation in constituent societies and forcing African American physicians to create their own, separate organizations. A second watershed involved AMA-promoted educational reforms, including the 1910 Flexner report. Straightforwardly applied, the reports population-based criterion for determining the need for phySicians would have recommended increased training of African American physicians to serve the approximately 9 million African Americans in the segregated south. Instead, the report recommended closing all but 2 African American medical schools, helping to cement in place an African American educational system that was separate, unequal, and destined to be insufficient to the needs of African Americans nationwide.

Deciphering Percival’s Code

Thomas Percival died in 1804, the year after the publication of Medical Ethics, 1 leaving nineteenth-century physicians free to appropriate his words without fear of contradiction from their author. The appropriation process began just four years after Percival’s death, when the Boston medical society used his language to draft their medical police of 1808.2 As American municipal, county, state and national medical organizations organized themselves from 1808 to 1846,3 they followed the Boston precedent of prefacing their charters with codes of medical police or ethics, borrowing most of their language from Percival.4 The process culminated in 1846 with the founding of what was to be the first national medical society, the American Medical Association (AMA). As the AMA still acknowledges, its original code of ethics drew heavily on Percival’s words.

Visibility and the just allocation of health care: a study of age-rationing in the British National Health Service.

The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner largely invisible to patients, to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories.

What is the History of Medical Ethics

INTRODUCTION This chapters title is an interrogative: “What is the history of medical ethics?” Readers perusing the table of contents might be prompted to ask precisely this question. The expected chronological account seems hidden behind a facade of unfamiliar rhetoric about discourses, life cycles, and society. Our approach reflects a new era of scholarship on the history of medical ethics. Because readers may not be cognizant of the new scholarship, we introduce this volume with a chapter exploring the history of the history of medical ethics and the reasons why scholars have begun to take new approaches to the subject. HOW OLD IS “MEDICAL ETHICS”? Histories have to begin somewhere. The expression “medical ethics” was not coined until 1803, when Thomas Percival (1740–1804), a physician from Manchester, England, introduced it in his eponymous book Medical Ethics (Percival 1803b) as a description of the professional duties of physicians and surgeons to their patients, to their fellow practitioners, and to the public (see Chapters 18 and 36). As Percival was the first person to use the expression medical ethics, there is a sense in which the history of something designated medical ethics cannot predate 1803. Most historians, however, treat the history of medical ethics as coextensive with the history of medicine. They presume that it does not matter when the expression medical ethics was coined. As Juliet famously remarked, “Whats in a name? A rose by any other name would smell as sweet.”

Medical Ethics, History of

This article reviews the development of medical ethics from the ancient Greek Hippocratic Oath, through the Renaissance, to the birth of modern medical ethics in Enlightenment Edinburgh, to the Bioethics Revolution. Emphasis is given to the writings of Scribonious Largus, a Greek physician practicing in first-century Rome; Marcus Tullius Cicero, the Roman philosopher; Rodrigo a Castro Lusitanus, a refugee Jewish physician practicing in Renaissance Hamburg; and Thomas Percival, a late eighteenth-century physician practicing in Manchester, England, who coined the expression medical ethics. Subtopics include the history of ethical views on abortion, euthanasia, and ethical research on humans and animals.

The Discourses of Orthodox Christian Medical Ethics

INTRODUCTION: BEFORE AND BEYOND THE SCHOLASTIC–ENLIGHTENMENT PROJECT There is a continuity between the commitments of the Scholasticism that emerged in the thirteenth century and the Enlightenment project of providing a discursive rational account of proper moral probity. Although the Enlightenment attempted to give an account of morality undirected by revelation and ecclesiastical authority, thus involving a substantive break with previous moral and political assumptions, the Enlightenment as well as Scholasticism share a substantive commitment to reasons abilities to provide a universal account of morality. Bioethics as it took shape in the 1970s reflected a late-Enlightenment attempt to provide a secular surrogate for the religious moral authorities that had once guided the West (Engelhardt 2002). Secular and Western Christian bioethics have drawn on philosophical assumptions regarding the capacities of discursive reflection. They both have a penchant for identifying moral truths with the deliverances of systematic moral reflections. In contrast, Orthodox Christianity lives in an understanding of morality unaltered by Scholasticism, the Renaissance, the Protestant Reformation, and the Enlightenment. Orthodox Christianity understands the moral life to be a whole, a way of life within which one can enter into union with God. Orthodox theology, morality, and bioethics identify this way of curing the soul of self-love such that distinctions among dogmatic theology, moral theology, and liturgical theology threaten to distort and disorient the lived appreciation of theology as a practice transcending the confines of the academy.

The Discourses of Buddhist Medical Ethics

INTRODUCTION There are three major branches of Buddhism called Theravāda, Mahāyāna, and Vajrayāna. Although they developed sequentially in India, they eventually overlapped and all spread beyond Indias borders. Over time, Theravāda became associated primarily with Sri Lanka and Southeast Asia, Mahāyāna with East Asia, and Vajrayāna with Tibet. Buddhism died out in India, the land of its birth circa 1300, although it has been making a comeback in the modern period with its conversion of the Dalits. Buddhism denies a Supreme Being or Absolute. It also denies revelation. Its concept of enlightenment is based on insight into the very nature of reality framed by the law of karma (the law of reaping what one sows) and cosmic and individual cycles of existence ( saṃsāra ). Its doctrines of no-soul ( anātman ), impermanence ( anitya ), and becoming ( pratītya - samutpāda ) collectively produce a spiritual existentialism, which has as its sacred authority the experience of liberation ( nirvāṇa ). As in Hinduism (see Chapter 9), religion, philosophy, and medicine have been integrated into a “way of life” and telos that include both spiritual and rational orientations. The place of ethics in Buddhism, however, is hotly debated. There are two prevailing views. One is that the Buddhas teachings and path are provisional, a raft to be eventually left behind. In this view, ethics (rules and virtues) are instrumental, and epistemology has two levels (provisional knowledge and truth). As a result, ethics cannot be made into absolute or universal rules and enlightenment is not characterized by goodness.