The Grasp of the Past

Hippocratic, Religious, and Secular Medical Ethicsby Robert M. Veatch

Georgetown University Press. 256p $29.95

Robert M. Veatch is instantly recognizable to all specialists in the field of bioethics as the leading and long-term opponent of the effort of the Hippocratic tradition across two millennia to locate medical ethics solely within the medical guild and to assert the guild’s right and duty to define—for both professionals and their patients—their reciprocal obligations. Hippocratic, Religious, and Secular Medical Ethics brings together a series of themes that unfold across Veatch’s entire professional life in works like A Theory of Medical Ethics (1981) and Is There a Common Morality? (2003). It is the author’s magnum opus on medical ethics set within a scholarly, historical framework.

In keeping with his long-held opposition to the Hippocratic tradition, Veatch finds “peculiar” both the original Hippocratic Oath of initiation (as it invokes those “strange” Greek gods of Asclepius, Hygeia and Panaceia) and its Code of Ethics (especially its proprietary and paternalistic cast). He also finds the later continuation of Hippocratism as an ethical theory “bizarre and absurd.” In effect, professionals, so subscribing, become a sect, morally. They cut themselves off from the broader world of ethical discourse. By claiming that professionals have both peculiarly received (and/or invented) and remain the sole interpreters of the norms they profess, they split themselves off from both religious and secular derivations of principles for medical practice.

His animus toward the sectarian/authoritarian and paternalistic aspects of the Hippocratic Oath keep Veatch from exploring some additional interesting questions. For example, are the gods simply “strange,” or do Asclepius and Hygeia, respectively, also suggest different features of health care that need to stay in some balance—acute care and preventive/rehabilitative care? Although the virtues of holiness and purity may originally reflect a primordial dread of contamination by blood, perhaps the cultivation of the virtue of purity (integrity) today might help protect the current practice of healing from the contaminations of fame and cash.

Veatch argues that we need to move today beyond a wholly intramural, professionally generated medical ethics to the grounding of its principles more broadly in religious and/or secular ethics. Theologically, he is less sympathetic to the effort to ground those medical principles in revealed religion (Karl Barth, Stanley Hauerwas, Oral Roberts) than in those religious traditions that open out toward a natural theology (Roman Catholic, Calvinist and Wesleyan). Veatch does not put to rest such principles in a fully developed doctrine of human nature of the sort associated with natural theology. He continues to argue for the concept of a social contract that establishes the ground rules for all our particular dealings with one another, including issues in health care.

Characteristically, Veatch is also more interested in linking religion and medicine with principles than with the virtues germane to medical practice and patient health. The virtue theorist Alasdair MacIntyre, for example, is mentioned but given short shrift. Tellingly, the Wesleyan tradition elicits Veatch’s interest primarily for its appeal to Scripture, tradition, reason and experience (as providing a wider space for the grounding of principles or norms in medical ethics), not for its contributions on the subject of the virtues and health. Veatch overlooks the huge impact of the Methodist tradition on the virtues and habits of the working class that led Robert Morrison to designate John Wesley as the greatest public health officer of the 18th century. Theologically, the Wesleyan emphasis on the doctrine of sanctifying grace helped inspire the Methodist concentration on self-improvement, whether intellectual (in the form of institutions like Chautauqua) or moral and health- giving (in the form of abstemious habits).

Veatch’s basic interest in the grounding of principles rather than virtues and habits carries through in his treatment of secular ethics and professional ethics. There he deals chiefly with debates about the relative weight and number of principles proposed by academic theorists in the field of medical ethics. He painstakingly notes that the number of principles urged by any given theorist varies from one all the way up to 10. (He himself weighs in recommending alternatively seven or nine principles.)

On the face of it, the proliferation of principles would seem to undercut the possibility of their stable grounding. Thus, in an interesting move, Veatch seeks to rescue the authority of secular ethics from a possible descent into chaos by observing that most principle-oriented theorists find a way of accommodating claims to other competing principles into their schemes as they organize moral discourse. Their recognition of the importance of doing so suggests a “pre-theoretical common morality” underlying the sometimes waspish debates over principles among academic theorists in the field. This pre-theoretical morality drives thought today toward what Veatch calls “convergence”:

It is not unreasonable to conclude that, among the normative theories in biomedical ethics that are derivable from natural methods such as reason and experience, the differences are relatively minor, minor enough to be explained by the limited perspectives of various theorists and the necessity of choosing arbitrarily a language for describing what can be called the common morality.

Veatch’s book ends on a positive note. He sees in the Universal Declaration of Human Rights (1948), followed by the Universal Declaration on Bioethics and Human Rights (2005), the right way to proceed from the universal to the particular, from the broader social contract to the eventual dynamics of doctor/patient relations. This final vantage point is somewhat aerial, working from the top down, a little far removed from the helter-skelter of a health care system down below and up close, which, in this country, often seems too rapid-fire, specialized, disaggregated, discontinuous and opaque to fully honor either the doctor’s calling or the patient’s plight.

However, Veatch carries forward the conversation on the subject of principles, and particularly their authority, at a time when the Hippocratic Oath (despite the blizzard of medical school and professional codes) is, in Veatch’s word, “dead”; and when theorists, religious and secular, seem to offer in its place only a cacophony of contending voices, too easily dismissed. Patiently, Veatch discerns and argues for a pre-theoretical morality at work in our current labors that point toward a convergence. The pluralism of our times need not lead inevitably to relativism in medical ethics.