A Quibble with Baker’s Before Bioethics

My pile of books to read over this past Christmas and New Year included Baker’s recently published ‘Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution.’ I was asked to review it for Social History of Medicine and have duly done so (short version: it’s very good and you should read it if it is of interest to you or relevant to your work in anyway). However, one thing caused me some disquiet that, due to the constraints of length, I did not get the chance to address in my review. It is a very minor point and the relevant text in Baker’s book is about three pages long. Regardless, it has stayed with me so I thought I would tackle it here. 

In his Chapter ‘Explaining the Birth of Bioethics, 1947-1999’ Baker has a section ‘Research Oversight: The Origins and Atrophy of Professional Self-regulation’ (p.281). It is subtitled ‘Percival’s Proposal for Research Ethics Committees.’ The reference is to Thomas Percival (1740-1804), a founding figure in the codification of medical ethics and, therefore, the professionalization of medicine i.e. the social institutionalization of medicine as a profession.* Interestingly Percival’s writings exerted their clearest and most immediate influence on the emergence of the American medical profession and not in the UK, where he lived and worked. 

My complaint lies with the way Baker attributes the notion of not only ‘research ethics’ to Percival but also the idea of ‘Research Ethics Committees.’ I do not think either of these claims resist scrutiny. The primary support offered is the following extended quotation of Percival’s Medical Ethics:

“Whenever cases occur, attended with circumstances not hitherto observed, or in which the ordinary modes of practice have been attempted without success, it is for the public good, and in an especial degree advantageous to the poor (who, being the most numerous class of society, are the greatest beneficiaries of the healing art) that new remedies and new methods of chirurgical treatment should be devised. But in the accomplishment of this salutary purpose, the gentlemen of the faculty should be scrupulously and conscientiously governed by sound reason, just analogy, or well authenticated facts. And no such trials should be instituted, without a previous consultation of the physicians or surgeons, according to the nature of the case.” 

                                                                     Percival, Medical Ethics 1803, Chapter 1, article XII, 14-15 cited in Baker 2013: 283.

In the first instance there is no mention of ethics in this passage. Whilst it would be correct to say that Percival promotes consultation as the (ethically) correct course of action when contemplating a new remedy this is to ensure the ‘scientific’ probity of the remedy and not to discuss any specifically ethical dimension of testing the remedy on some particular patient. Percival’s suggestion is that just as the medical man contemplating a previously untried treatment would be well advised to examine the current literature they would be similarly advised to discuss their plans with a suitable qualified other. This is not an ‘ethics of research’ but an ethics of operating at the limits of knowledge, something which can characterise much medical practice of the period. The consultation is not an ethical one but one pursued in the interests of ‘best practice.’

Baker seems to recognise this point as he omits the word ‘ethics’ from the title of the following section ‘The First American Percivalean-Style Research Committee’ in which he discusses ‘Percivalian-style research review committees’ (p.283). However, we might also consider if the activities Percival refers to are, in fact, examples of ‘research.’ In the passage cited Percival makes no mention of ‘research’ and whilst the terms ‘trial’ and ‘experimental’ are in common used at this time, these terms did not have the same meaning then as we apply to them today. Then they meant ‘untested’ and there is no concomitant sense in which a programme of testing is to be pursued. Certainly unusual cases of illness of treatment would be reported in the medical literature of the time but, again, this case-by-case activity is not what we mean by research today. 

The 150 years following Percival’s ‘Medical Ethics’ saw the gradual emergence of various activities that we would today call medical research. However, it was not until the 1950s that anything we could call an ethics of research or a ‘Research Ethics Committee’ was established. The evidence for this can be found the two recent books, Schrag’s Ethical Imperialism and Stark’s Behind Closed Doors. Stark points to the way ‘biomedical research ethics’ and, in particular, the ethical review of biomedical research by ‘expert committee’ was conceived and invented by the National Institutes of Health, Bethesda, Maryland, USA circa the 1950s whilst Schrag tracks the way this approach was gradually exported both geographically - across American and beyond (cf. Hedgecoe) – and intellectually – as part of the governance of ‘research’ as a whole. 

Baker’s position seems to imply that much of 19th century medical practice must be seen as research or, alternatively, that ‘research’ was not an activity that could be seen as alien to everyday medical practice. Interestingly this is something that a number of leading bioethicists have recently proposed and debated with regard to 21st century medical practice. However, a major point of the contemporary discussion is whether the research-treatment distinction can be maintained and thus whether the distinction between ‘(biomedical) research ethics’ and ‘clinical’ or ‘professional’ (medical) ethics can be maintained. Given that the relevant sense of research did not exist in Percival’s time we cannot take any of his recommendations as being examples of research, as opposed to medical, ethics. The distinction between biomedical practice and biomedical research emerged in the era between Percival and now and the distinction was and is assumed by bioethics. If it is once again collapsing we may have to consider if thinking in terms of a specific ‘ethics of research’ continues to be a fruitful perspective. 

* This did not formally happen in the UK until the General Medical Council was established by the Medical Act 1858. Prior to this medicine (and allied fields) are best understood as Guilds and, in actual fact, the GMC resisted adopting any codified ethics for at least the first 100 years of its existence. Nevertheless, it is true to say that, codified or not, a profession without ethics is no profession at all.