Abstract

In lieu of an abstract, here is a brief excerpt of the content:Bioethics in the Twenty-First Century: Why We Should Pay Attention to Eighteenth-Century Medical EthicsLaurence B. McCullough (bio)Those of us who work in the field of bioethics tend to think that, because the word “bioethics” is new, so too the field is new in all respects, but we are not the first to do bioethics. John Gregory (1724–1773) did bioethics just as we do it, at least two centuries before we thought to do it (Gregory 1772). He deployed philosophical methods as sophisticated as our own. Indeed, Gregory took up the very best moral philosophy available to thinkers of the Scottish Enlightenment, namely, David Hume’s moral philosophy and its core concept of sympathy. Gregory also responded in a conceptually powerful and clinically applicable way to the problems of his time, just as we do. I want here to outline Gregory’s accomplishment and to identify some aspects of its importance for bioethics in the twenty-first century.Gregory’s “Problem List”Gregory wrote his medical ethics as a response to the then current state of medicine in Britain. We now follow Gregory in our writing of bioethics and clinical ethics in response to the problems of our time. A great deal that we now take for granted did not then exist. 1There was not, as there is now, any uniform pathway into medicine. Nor did there exist universal licensure. The Royal Colleges did attempt to assert, but failed to achieve, monopoly control of medical practice. The concepts of health and disease were themselves contested and therefore competed for their success in the market place. There was a marked oversupply of practitioners who competed fiercely—very fiercely indeed—in the medical market place for their concepts of health and disease, their treatments, and therefore their livelihoods. Patients had their own concepts of health and disease, engaged in “self-physicking” or self-care, and often traded physician’s prescriptions.Medicine exhibited little scientific discipline in its accounts of disease and in determining the efficacy of treatments, a fact that Gregory (1743) laments as a [End Page 329] medical student. There was no marked improvement when he began to give his medical ethics lectures nearly a quarter of a century later. Treatments failed as often, perhaps more often, than they succeeded in benefiting patients. The sick usually sought out the help of a physician after trying self-physicking.Physicians, Gregory taught, could not hope to control human biology, though they could aim to manage its processes well. When nature underresponds to disease the physician should assist her processes; when nature overresponds, the physician should tamp down nature’s responses, to lessen their “violence”—in both cases always attentive to the limits of medicine’s capacities in treating disease.Physicians attended the well-to-do sick at home, and the sick person summoned and dismissed physicians, surgeons, or apothecaries at will. A physician therefore might find himself—no women had yet been admitted to the ranks of university-trained physicians—summoned before, after, or simultaneously with a competitor, with his concepts and diagnosis and treatment put to the acid test. In this setting, there existed only a patient-physician relationship, not a physician-patient relationship.Physicians left off the care of dying patients, a practice that was made a matter of duty by Friederich Hoffmann (1749). One would suffer punishing economic consequences if one had a high mortality rate. Better, then, to label the patient incurable, withdraw, and turn matters over to clergy. Gregory attacks this practice as intellectual fraud and calls for the physician to continue to attend the dying. Indeed, he says, “It is as much the business of a physician to alleviate pain, and to smooth the avenues of death, when unavoidable, as to cure diseases” (Gregory 1772, p. 35). He does not explicitly address what we now call physician-assisted suicide; neither does he condemn it, and he is quick to condemn some things—e.g., sexual abuse of female patients or “sporting” with patients in the Royal Infirmary by using experiments as the first line of treatment.The Royal Infirmary was established to care for the deserving, working poor, who received free care...