Meanings, Policies, and Medicine: On the Bioethical Enterprise and
History
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Citation
Rosenberg, Charles E. 1999. Meanings, policies, and medicine: On the
bioethical enterprise and history. Daedalus 128(4): 2746.
Published Version
http://www.jstor.org/stable/20027587
Accessed
May 28, 2016 8:54:52 AM EDT
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http://nrs.harvard.edu/urn-3:HUL.InstRepos:4730333
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(Article begins on next page)
E. Rosenberg
Charles
and Medicine:
Policies,
Meanings,
On the Bioethical Enterprise and History
can
One
we
hardly
ignore
are
living through
is more
that crisis
And
shared conviction
the widely
that
a period
care.
in health
of crisis
than economic
and administra
its most
themselves
present
tive, though
symptoms
egregious
forms. One need only pick up a newspaper
these interrelated
to be reminded
of the omnipresent
and multidimen
magazine
nature
sional
of
Many
of
the problems
those
perceived
the difficulty
as moral,
as well
and
change
nomic,
and
policy,
bioethics
research
is often
in
or
options
invoked?as
American
medicine.
confronting
turn on rapid
dilemmas
technical
an institutional
of creating
and eco
context
in which
can
be managed.
both symptom
these
new
clinical,
Not
surprisingly,
rem
and possible
are we
to
How
of these
discussions
realities.
edy?in
jarring
site it in social
think about
this enterprise,
and under
space,
are not
its several
stand
interrelated
identities?
These
easy
a
constitutes
tasks.
bioethics
elu
Contemporary
particularly
sive
for the historian;
value assumptions
have always
challenge
as
a
social
those
values
medicine
have
yet
enterprise,
shaped
common
sense
been often
and unspoken,
the moral
of
implicit
each
with
technical,
generation
interacting
to configure
economic
and
factors
tutional,
of clinical
realities.
Charles
E.
history
and
17
Rosenberg
sociology
professional,
a time-specific
is Janice
and Julian
in the department
Bers Professor
at the University
science
of Pennsylvania.
of
insti
set
of
the
Charles E. Rosenberg
28
MEDICAL
For
CARE AND
this historian
SOCIAL OBLIGATION
medicine,
are particularly
contemporary
change
in 1998
for example,
Times,
reported
had announced
its intention
of entering
a for-profit
corporation;
cancer
clinics.
and HIV
America's
Hospital,
it planned
"The No.
the president
own
In my
institutions,"
formation."1
some
of American
oldest
of the markers
The
striking.
that Montefiore
New
of
York
Hospital
into a joint venture with
to open a chain of 24-hour
1 problem
for not-for-profit
of Montefiore
"is capital
explained,
the
city, Philadelphia,
Pennsylvania
first sold its histori
general
hospital,
division
important
psychiatric
sold itself, after an independent
a millenium,
to a rather more
youthful
cally
then
a for-profit
provider,
existence
of a quarter
of
the Univer
entity called
to
Health
its plans
announced
sity of Pennsylvania
System, which
to
to send four "experts
in 'clinical
look
for
ways
reengineering'
to make
at its new
in clinical
care"
cost-effective
changes
The Hospital
of the University
of Pennsylvania
acquisition.2
more
its own
Even
had just finished
"reengineering."
recently,
the Philadelphia
health-care
has been destabi
system
region's
lized and demoralized
takeover
of a
strategy
by the aggressive
health-care
which
system,
purchased
Pittsburgh-based
physi
in a
cian practices,
and
associated
medical
schools
hospitals,
unmet
in bankruptcy,
that soon ended
a perilous
future for such historically
signifi
as Hahnemann
Medical
and the Medi
College
venture
bold marketplace
commitments,
cant institutions
cal
College
of
and
Pennsylvania.3
of
collection
my
among
revealing
Particularly
an
is
indicators
ironic?and
enlightening?juxtaposition
ries on the front page of the New
York Times.4
right-hand
corner
was
(NIH) funding was
a report
that National
recent
media
of
sto
In the upper
of Health
Institutes
likely to be increased in next year's budget.
cancer
and treated.
could be understood
explained,
in a golden
of
the
director
of the
age
discovery,"
"one
in
Cancer
Institute
National
(NCI)
contended,
unique
.
.
.
nature
human
about
the fundamental
history.
Knowledge
in on mankind's
is exploding."
Basic science was closing
of cancer
And,
"We
ancient
relied
it was
are
and
enemy,
on to nurture
relentless
this
could
lobbying
Washington
A
laudable
coalition
enterprise.
be
of
interested
and medical
groups,
doctors,
advocacy
an
to
in
effort
double
the NIH
supporting
joined
cam
a
next
"We
five years.
the
grass-roots
plan
the president
of their
and outside
the Beltway,"
parties?patient
schools?had
over
budget
inside
paign
29
Policies, and Medicine
Meanings,
lobbying firm explained candidly: "It will be run the same way
Grumman
Northrop
lobbies
for
the B-2
bomber."
to the left of this upbeat and uninflected
a background
was
achievement
laboratory
story
pain associated with
tional and physical
on
emo
the
births
the multiple
treatments:
fertility
read one of the
from contemporary
resulting
row follow Medical
Miracle"
Immediately
report of promised
"Joy and Sor
in this
subtitles
on
overview.5
Whether
the placement
of these stories
sobering
a compositor's
or an
was
of the Times
whim
the front page
seems undeniable.
the message
Tech
editorial
comment,
implicit
market
nology,
are changing
been
less
such
and
have changed
policy
while
care,
society
in anticipating
the consequences
incentives,
public
of medical
every
aspect
than successful
and
has
of
change.
The Fall 1998 special issue of Life, to cite a related example,
was
devoted
The
cover
to
"Medical
"21
promised
Miracles
the Next
for
That
Breakthroughs
Millennium."
Could
Change
Your Life in the 21st Century: Gene Therapy/Edible
Memory
Drugs/Grow-Your-Own
in the magazine's
worshipful
paid
to the
spread
ironic
fear
illuminating
The
subtitle
us
and
seemingly
was
technology's
an issue of Time
promised
in the next
of
depiction
paradoxical
human
that
of
Little
Organs."
to explain
on
"The
"how
Vaccines/
attention
laboratory
of
growth
progress
a wide
Similarly
implications.
Future of Medicine."
will
engineering
cover
illustration
striking
head morphing
into a coil of
genetic
The
century."
change
was
a stylized
a snake's
caduceus,
to symbolize
DNA.6
How
better
medicine's
and
changing
a
in
flicted
world
of relentless
progress
laboratory
shape
media-heightened
visual metaphor
yet mutually
the technical
public
represents
constitutive
and
the
was
expectations?
as well
two
The
cover's
seemingly
of contemporary
cultural
of
power
of a self-conscious
ethical
aspects
sacred?the
and the persistence
novelty
I would
that this brief sampling
argue
vides a useful microcosm
of a structural
of media
and
con
and
powerful
inconsistent
medicine:
laboratory
tradition.
pro
reports
macro
emotional
30
Charles E. Rosenberg
cosm.
but
a perceived
in public
crisis
policy,
between
values
and expecta
inconsistency
as the concrete
social and economic
relationships
not
It illustrates
only
a fundamental
as well
tions,
in which
such
convictions
and
perceptions
are necessarily
em
bedded.
Our
health-care
on
nect:
hand,
and the market,
laboratory
to the human
and respond
tional
innovation.
expansive
are well
always
aware,
amenable
such
elements
of
question,
of
implications
dilemma
solutions
of
are both
encounter
MEDICINE
institu
of our
grows
directly
to clinical
problems;
and
death
In the
late
issues
public-policy
some
sense weighing
and
of professional
autonomy,
individual
I would
as we
are
not
twentieth
and,
inevi
issues
the move
and
takes
to the
encounter
clinical
understanding
and collective
that bioethics must
contend
such
that
are
from
in terms
larger
society
the
ulti
necessarily
individual
of medicine,
in which
that
place.
AND MEANINGS
a historian,
are
medicine
To
vious
American
thus
obligation,
Montefiore
and
out
questions
and unavoidably
moral:
to structure
from meaning
social,
the
technical
in individual
The
doctor-patient
relationships.
to the general,
is relating
the particular
course,
in recurring
the choices
that
face
individuals
address
to the
from
this
conflicts
social obligation.
mately
historical
on
sickness,
pain,
disability,
to clinical
intervention.
understanding
interactions?in
social
degrees
boundless
in technical
faith
century,
tably,
And
discon
by a characteristic
in the power
faith
of the
a failure
to anticipate
the other
is marked
system
one
the
of
many
strikingly
the dilemmas
Home
beset
contemporary
in pre
realities
parallel
The world
of social
and
value,
when
the
for
different,
example,
different
generations.
was
very
that
for Chronic
from
Invalids opened
its doors
in
was
when
the Pennsylvania
estab
certainly
Hospital
ex
in the 1750s.
Pious
and paternalistic
the
activism,
care
were
as
to
of
for
the
central
deference,
change
eighteenth
as monetary
and early
exchange
nineteenth-century
hospital
1884,
lished
was
and
alien
determined
to
it. Class
one's
place
as much
as diagnosis
and dependence
care sited largely
in a "system"
of health
Meanings,
in the home,
and in which
to the urban
poor.7
tially
institutional
term
with
"health-care
system,"
bureaucratic,
multilayered,
public world
In
of medicine,
31
Policies, and Medicine
care was
essen
limited
the late-twentieth-century
fact,
its assumption
of a complex,
interactive,
and,
by implication,
to an era without
is irrelevant
special
an era in which
the great majority
of
laboratories,
care was performed
in the patient's
whether
home,
by
or professional
The worthy
poor
physicians.
family members
care without
were
to deserve
in
voluntary
hospital
presumed
ists
and
medical
that came with
the stigma
almshouse
admission.
curring
Physi
an
to
to
cians were
have
gratu
presumed
obligation
provide
care to those unable
to afford
itous or discounted
their fees.
Whether
or
rural
urban,
a right
to have
presumed
nineteenth-century
to such care, but
were
Americans
not,
of
course,
to
equal?class-blind?care.
sector played
The public
a role in the provision
of health
seen as
to the dependent,
not to those
in regard
care,
only
care
sense
to
A
able
for themselves.
constructed
of
socially
of
moral
motivated
and
categorical
obligation,
stewardship,
but
shaped the efforts of our earliest hospitals'
founders. They did
responsibly
or failure
of
judged primarily
by
were
to
decisions
function
(though
they
expected
was
the market).
within
The medical
profession
presumed,
at
not
expect
marketplace
to be
gentlemanly
like advertising
as evidence
to be motivated
theory,
benevolence;
patenting
clinical
for
services?was,
in
least
and
selfless
competition
efficient
economically
tion for misrepresentation
1800,
distributed
and
ideas
and
society?in
throughout
we have become
to which
those
eth
medical
century.
Conventional
ideas
professional
but were
ample,
specific,
of
not
moral
disease
shoddy
medical
practice.
practice
patterns
accustomed
values
causation
were
different
vastly
in the
widely
from
late
twenti
suffused
both
lay and
for ex
treatment,
notions
of
of modern
and
in terms
legitimated
mechanism-defined
disease.
Disease
logically
enough,
ings of behavioral
of
not rational
quackery,
was understood
to be not a guarantor
of
care but an ever-present
motiva
health
sordid
Economic
In
by a code
discoveries?
seen
example,
market
behavior.
one's
of
success
the
so prominent
a role
play
or
in
deviance,
physicians'
did not,
categories
in lay understand
understanding
of
32
Charles ?. Rosenberg
and
appropriate
therapeutic
a willed
was
behavior
disease,
act
Homosexual
not a
example,
a variety
of
among
for
immorality,
or merely
one
type,
personality
choices.
diagnostic
of
were
children
patterns;
disruptive
grammar-school
not victims
and undisciplined,
of Attention
Deficit
Hy
con
Disorder.
Death
involved
and pain,
peractivity
prognosis
a patient's
frontation
with
and aggregate
spiritual
physiologi
lifestyle
wicked
cal
of
not
status,
bureaucratic
meant
the management
protocols
that?an
literally
ment
of
a transcendence
body
Chronic
volition,
tors and
men
And
of
loved
My
tried
of
traditional
as well
continuities
and
late
the
as
religion
and
contrasts
be
twentieth
centuries.
for example,
of behavior,
disease,
questions
posed
as today's
anxieties
and regimen?just
risk fac
about
mobilize
of
and
lifestyle
feelings
guilt
accountability.9
and women
felt pain,
feared death, mourned
the loss
ones?as
argument
to illustrate
will
they still do.
have become
and
and
historical.
and
Medical
incorporated,
and
ideas
sanctioned
ethical
Such
responsibility.
constrain
choice;
meaning
and inextricably
embedded
and
public,
I have
enough
by now.
in which
the way
morality
are unavoidable
responsibility
clear
terms
in concrete
moralism,
obligation
elements
of medical
care,
NOVEL
the hegemony
Euthanasia
the deploy
implied
not
family,
respirators
to em
had not yet come
that
rivaling
and
private
schemes.
and
reflection,
Research
community
obligation.
There
are, of course,
tween
the
late eighteenth
and
insurance
death?and
easy
moral
opiates,
advanced
directives.8
and
of machines
and
individual
same
at the
practices
time
always
notions
of
prevailing
assumptions
and morality
in every aspect
and
and
contingent
have
reflected,
value
and
and
priorities
imply
are thus necessarily
of medical
practice:
collective.
REALITIES
can be
If anything
in the relationships
said
to characterize
the
our
moment
particular
histories
of medicine,
a novel
I have emphasized,
linked
among
it is, as
and public
culture,
policy,
an uncomfortable
sense of change
and conflict,
in balancing
inherent
the difficulties
the sacred
awareness
and
the
techni
of
and
cal, the individual
individual
of physicians,
out
in fact,
oped
1970s.
in configuring
the rights
It was,
the general
good.
that bioethics
itself devel
the
collective,
and
patients,
conflict
such perceived
movement
self-conscious
of
a
as
Its very
in the 1960s
and early
as a
in part a symptom?as
well
a
of
between
medicine's
gap
inequity,
humane
tradition
and a reality
often
an acknowledgment
It was
that some
was
creation
perceived
sacred
and
recognition?of
presumably
33
Policies, and Medicine
Meanings,
inconsistent.
egregiously
to be done.10
needed
thing
In another
this gap between
medicine's
humane
tradi
sense,
can
a
more
tion and
and compromising
be
complex
reality
a
as
a
in
crisis
structured
demand:
of
and
thought
supply
and
demand
constituted
and
the
inexorable
by pain
anxiety
and
of demography
in terms of procedures
realities
strued
produced
a world
a reservoir
of
of
chronic
and
insatiable
dominated
supply
and
and
costly?providers
This
asymmetry
ity of far-sighted
embodies
by
technology,
products.
a structured
scientists
social
con
yet routinely
Americans
have
specialists.11
to
clinical
demand
ill-suited
disease,
by
conflict
impersonal?
a minor
that
and
have
warned
physicians
at
since the progressive
about
the beginning
of the present
a
when
such critics
medical
century,
growing
imper
deplored
on what
saw as increas
and dependence
sonality
they already
in fact, be
Such anxieties
technology.
ingly pervasive
might,
seen as precursors
move
of the late-twentieth-century
bioethics
era
ment?an
of
affirmation
to
opposed
implied
by
the
clinical
the
individual
depersonalization
pathology,
and
health
and
and
specialism,
We
disease.
as
the
idiosyncratic
of
fragmentation
and
care
un
reductionist
a
of
have
derstandings
experienced
in how we think about medicine
crisis
of recurrent
and
century
seem
a
to
from
it.
We
what we
in
created
have
expect
system
which
material
which
we
personal
through
expectations
and
increasingly
is,
(that
technical
are
bound
to disappoint,
and
in
to reach
keep
trying
and
holistic)
ends,
intangible,
experiential,
and mechanism-oriented?reductionist?
paradoxically
means.
Another
more
recent
concretely.
causation
genetic
bit
of media
Newsweek
not
only
evidence
illustrates
featured
recently
of clinically
this
an article
well-defined
point
on the
mental
Charles E. Rosenberg
34
of a bewildering
of human
variety
peculiarities,
as less severe manifestations
all construed
ailments
(shadow
one
or
more
caused
the
of
"abnormal"
of a
presence
by
genes)
also
but
illness
illness.12
multi-genic
once
quirks
thought
sense, mental
of
reflection
behaviors
"Idiosyncratic
'odd'
merely
or
and
'interesting'
the Newsweek
illnesses,"
an abnormality
in the
personality
be, in a
might
"a
reporter
explained,
even
in
and
brain,
the
genes."
Though
mentioned
at first
perhaps
as Montefiore
changes
and
the
social place
a fundamental
and
medicine:
twentieth-century
nism-based
understandings
behaviors.
deviant
This
sheds
mechanism.
story on
everything?of
think
about
ourselves.
how
reduced
a number
reality
to do more
Perhaps
and expectations
we
range of human
both
and
normal
supplementary
health-care
and more
the
increasingly
metastasizing
news
pages;
but
on
light
a
the
system:
cultural
work,
legitimate
norms,
illustrated
in
of practically
manage
deviance,
itself can be
culture
agency,
Behavior,
to neurochemical
mechanisms,
even
if this
a
to maintain
to dismay
those anxious
and individual
agency
responsibility.
ideas and institutional
of linked
relationships
become
in economic
market,
for mecha
search
It is in part a crisis?as
the genetic
determination
of problems
fundamental
most
deviance,
in which
and
story
of
aspect
continues
for human
place
structure
This
in which
of
in our
of biological
the Newsweek
and
ever wider
related
under
that this cultural work be legitimated in terms
while demanding
poses
an
a parallel
structural
ingenuously
determinism
logically
its characteristic
medicalization
to ask medicine
tendency
or to
Hospital,
this newsmagazine
in fact
of
relentless
behavior
fundamental
historically
Pennsylvania
of bioethics,
the
standing
illustrates
to the previously
institutions
significant
unrelated
thought
in such
for both
historian
and
bioethicist.
in which
is the way
ideas, values,
in institutions,
in practices,
is the way
and interests.
Second
embedded
relationships
of medicine
have become
and practices
concepts
to the everyday
and women,
central
lives of men
as well
as the
on to the business
and editorial
we
seem well
almost
medicine
a paradox
on
to medicalizing
the way
life. Third
of daily
aspect
every
is simultaneously
that
frames
today's
within
most
not
and
just
is the way
the
outside
vexing
organiza
35
and Medicine
Policies,
Meanings,
Can
the market
(as mediated
question:
through
public
as
a
means
the
and
prove
process)
advocacy
political
adequate
is
of distributing
clinical
and outputs,
when
demand
equities
tional
in more
defined
rational
than material
rationalized
and
Can
terms?
the market
solutions
(collective)
emotional
produce
that must
be
in moral
and
terms?
(individual)
experienced
as
to
I
The
is that we
bottom
have
tried
line,
emphasize,
remove
or isolate
cannot
value
from
the institu
assumptions
men
in medicine;
the technical,
and the conceptual
and
tional,
women
express
inevitably
sphere. Medicine
public
their
sense
of need
is negotiated
and priority
in the
and inevitably political,
more
to understand
and, as we have come
cal is cultural.
The heated
contemporary
the politi
generally,
debate
surrounding
concrete
the nature
of
way
care illustrates
in a very
managed
such interconnections
between
values
can
that
once
be
as matters
framed
questions
of
control
of
right and wrong,
tute de facto political
rival policies
among
tions.
and
interests.
and
of
and
justice
economic
Questions
are
autonomy
at
gain.
Perceptions
of practice,
consti
standards
appropriate
in negotiating
realities?variables
choices
as well
as in particular
interac
clinical
of
The
for example,
that it is right
assumption,
widespread
a role
to play
in providing
and
government
regulating
care is a specific
health
historical
and ethical,
and thus political,
so is the equally
And
that it is
pervasive
assumption
reality.
mere
to
somehow
immoral
for
economic
calculation
constrain
for
a physician's
clinical
to nurture
bioethics
medicine's
But
and
special
this
vague
unambiguous
decision
making.
constitutes
similarly
moral
identity.
consensus
moral
social
agenda
Our
in fact,
willingness,
a public
of
recognition
cannot
mandate
for bioethics.
The
a precise
new enter
prise has been charged with a difficult and elusive job.We
live
a world
in a fragmented
of ideologi
yet interconnected
world,
cal and social diversity,
of inconsistency
and inequity,
of change
cannot
and inertia. We
discuss
and
among men
relationships
women
in power
who
differ
and knowledge
without
acknowl
those
class,
edging
inequities:
geography,
education
all modify
the category
patient;
as well
as the institutional
and intellectual
cine
(such as specialty and organizational
gender,
economic
structures
and
race,
incentives
of medi
affiliation) modify
36
Charles E. Rosenberg
awareness
A growing
of such com
physician.
an increasingly
made
bioethics
labile
self
and
a
one
as
And
less
self-confident
enterprise.
perhaps
the
category
has
plexities
conscious
a foundational
applying
no
seems
an
actions
longer
well:
and
articulating
social
particular
goal.
Inconsistent
ideas
as well
for both
choices
rated
physician
not
internalized
and
a world
sus, but rather
by the claims
of
the
of
worship
millennialism,
undifferentiated
into
the
discourse
of
hopes
it
because
but
its
with
a widespread
and
It is a kind
simply
optimism,
and
expectations
of particular
always
tradition
research
application.
not
marked
consistent
for knowledge
search
powerful
cultural
and practice
not
and
competing
is the academic
in its inevitable
faith
attainable
easily
diversity
shape available
Our
and patient.
has elabo
society
a unified
consen
and coherent
moral
of medical
selfless
for
basis
social
three
One
transcendences.
as
ethical
of
is a
secular
source
of
it is structured
because
the career
into
individuals:
into the forma
and scientists,
physicians
status
into
and
of
and
the
programs
public
policy,
and
and
academic
Second,
teaching
hospitals.13
departments
as goal
more
is the worship
and
of system
the
recent,
ideal,
choices
tion
of
that
assumption
the optimum
general
good
market
of
configuration
an optimum
through
relationships.
specialness
the rights
is the
course,
for
respect
physician
tradition
patients?a
of
Finally,
of medicine,
of individual
is attainable
only
institutional
and
traditional
moral
and
responsibility
that can be
traced
over medical
to contemporary
debates
antiquity
care. Each of these claims
to transcendence
claims
legitimates
to social authority;
and
all are ceaselessly
reconfigured
configured
from
classical
as medicine's
and
fact
tions
pose
resources
technical
novel
research
become
already
that characterize
and
a substantive
relations
forms
institutional
evolve
Bioethics
clinical
and
options.
in the complex
these
realms
among
in
has
actor
interac
of
value
and
power.
implicit
I have
tried in the preceding
in which
the moral
the ways
historically
other aspect
modes
of
constructed
of culture,
that
analysis
pages
values
and
situationally
and not simply
have
historically
to
that
a number
illustrate
suffuse
medicine
of
are
negotiated,
derived
from
like every
the formal
characterized
theology
Policies,
Meanings,
an element
are in themselves
principle
that inform
and rationalize
credentialed
BIOETHICS AS HISTORICAL
ics
particular
to emphasize
lines medicine's
in which
tional
necessarily
as well
elements
of
this
bioeth
I have
discussion
because
Iwanted
a variety
embodies
as
technical
under
the way
of attitudinal
and
capacity
institu
practice.
relate.
from
First,
is a complex
ethics
investigation.
the historian's
academic
although
followed
separate
paths,
a sensitivity
sensibility,
bio
perspective,
for
revealing
subject
empiri
Iwould
contend
important,
in general
and bioethics
have
disciplinary
history
a potential
of
community
to the relationships
and
social
and
the
constraint,
they share
to context
individual
among
perception,
situatedness
of human
agency.
bioethics
The
still-brief
inhumanities
A
aware
of
of
history
and
the
finally,
similarly
importance
of the gap between
and prac
contingency,
theory
outcome.
intent and unforeseeable
just such realities.
the mid-twentieth
research.
Practitioners
be
should,
irony and
tice, conscious
of
inwhich bioethics and history
and potentially
and more
Second,
that
felt
I began
change
the history
of bioethics
in
and,
dependence,
particular,
But this is only one of the ways
cal
mediation
in which
the ways
context
medicine
value
negotiations
of
formulations
a claim
at once
SUBJECT
Thus,
anecdotally.
of
institutional
examples
with
The
of a socially
visible
called
enterprise
of the recurrent
structured
conflicts
very existence
is a recognition
to illustrate
tried
The
and
care).
are
theologians
a factor
in the public
and
authority
conflict.
in the social
health
and
philosophers
to cultural
social
of fundamental
(though such delineations
and moral philosophy
37
and Medicine
of American
history
As a social movement,
as a critical
century
bioethics
demonstrates
in
developed
a
to
response
enterprise,
care and biom?dical
of health
in our
system
to specific
bioethics
bioethics
has remained
abuses,
or at least
to
bioethics
solve
expects
society
practice-oriented;
ameliorate
visible
insistently
problems.
response
as it has
Growing
has had an undeniable
out
of a sense
impact
on
of moral
everyday
bioethics
outrage,
clinical
realities.
Yet
38
Charles E. Rosenberg
the historian's
from
this novel
has played
perspective,
enterprise
not only
in some ways
role.
Bioethics
ambiguous
in
it
has
the
past quarter-century
authority;
helped
it. As a condition
and
of its acceptance,
legitimate
a complex
and
questioned
constitute
has taken up residence in the belly of the medical
although thinking of itself as still autonomous, the bio
bioethics
whale;
ethical
has
enterprise
a complex
developed
this host organism.
tionship with
and
was)
free-floating,
oppositional,
in chairs
it is embodied
reform movement:
abundant
in
literature,
in presidential
technical
consent
and
forms,
It can, that is, be seen
and highly
bureaucratic
protocols.
complex
and
criticism
critical
socially
in an
centers,
review
boards
commissions
and
research
as a mediating
in a
element
that
neverthe
must,
system
an
not
It
is
accident
change.
linked
bureaucracy?
tuned language?
finely
implies
medicine's
a structured
conflict.
By
in
and
humane
benevolent,
serves
to
bioethics
identity,
ironically
a
in
and perpetuate,
often
and thus manage
system
In
this
with
that
idealized
sense,
identity.
principled
serves the purpose
of system
of the health-care
system
voking
even
sacred,
moderate,
conflict
role
functional
this
and
stature.
to moral
claims
But
and
institutional
ceaseless
technical
less, manage
that the bioethical
has routinely
enterprise
institutional
and
committees,
regulations,
with
is no longer (if it
Bioethics
a
ever
rela
symbiotic
representing
cultural
It is such
maintenance.
of power
paradoxes
and
consciousness
that explain why bioethics needs to think of itself both histori
and politically.
Bioethics
begun.14
And
cally
has
in some ways
this process
has already
its
and vil
enshrined
heroes
already
commemorated
and Josef Mengele?and
Beecher
lains?Henry
In fact,
its sacred places?Willowbrook,
Nuremberg.
Tuskegee,
one
the
initiated
that
historical
could
argue
stock-taking
by
is itself
generation
founding
consolidation.15
institutional
bioethics'
be
called
analytical
demonstrate
science.
emphasize
It
false
is difficult
her
and mystifying
celebratory
can be
ends. History
a
consciousness
and
celebration
self-critical
and
both
of what
serve
histories
Participant
as
an aspect
field's
for
positive
the
committed
values
and
practitioner
accomplishments,
might
as well
to
used
of con
not
to
not
to see herself on the side of the angels, fighting the good fight
routine
the
against
women
and
unself-conscious
and
protect
oned
the
rights
the medical
cence,
of
the
and
non-maleficence,
technology."16
Most
contemporaries
yet
self-evaluation,
have
characterized
as
insofar
clinical
it has
practice,
and thus
prises,
reform
cannot
moral
patient
as
justice
not
it has
so uncritical
be quite
to deal
still
ill-prepared
central
irony
the
been
of autonomy,
benefi
the antithesis
of
represent
principles
would
are
"in the late
explained,
has always
champi
the vagaries
of
against
medicine
Its cardinal
system.
a technol
to amelio
it sought
reader
individual
quote
of my
in which
I
a passage
in some ways
as
enterprise
the technology
ogy necessarily
mirroring
rate. "Bioethics,"
the indignant
in American
twentieth
century
let me
version
to
in particular
and
remarks,
the bioethical
and
research
patient
rights against
a technology.
as
itself
of example,
By way
nology
an earlier
to
of a bioethicist
the words
reacting
present
described
of men
abuse
It is equally
settings.
of committees
and regulations
that
an
the abuses
of
tech
impersonal
in everyday
clinical
to see the apparatus
difficult
39
and Medicine
Policies,
Meanings,
of
by
a part
criticism
and
its every
help but constitute
an
of
with
of
those
I
what
success:
bioethical
the world
accepted
become
in their
research
linked
and
enter
consequent
procedural
of biomedicine's
aspect
face.
public
As a specific
bioethics
presents
subject, moreover,
empirical
an elusive
as weighing
elusive
its ultimate
social
aspect?as
In
is
this
the
because
is an
bioethical
part
impact.
enterprise
of
three
activities.
One
is
the
aggregate
not-always-consistent
to
elaboration
of formal doctrine,
the job of individuals
trained
articulate
and address
I refer, of
normative
ethical
questions.
to those philosophers
and theologians
who
have sought
course,
a principled
to create
consensus
around
such policy-defining
issues as autonomy,
and justice. Second
is the role
beneficence,
of
in which
and
in mediating
bioethics
ticular
the
tioners
social
settings.
institutional
and
language
and
researchers
subjects. Third
figures
in public
day-to-day
I have
in mind
review
ritual
discourse,
the
problems
innumerable
in par
contexts
government
boards,
consent
of informed
aware
is the way
clinical
of
the
rights
commissions,
make
practi
of patients
and
in which
the bioethical
responding
in newspapers,
enterprise
periodi
40
Charles E. Rosenberg
recent
and?in
cals,
television,
derived
dilemmas
often,
In this public
innovation.
that
new
to manage
nally
research
choices.
several
capacity
moral
is a discernible
there
and
It is both
reassurances
of
oriented.
an
has
my
explains
I have
what
alarming
potentially
ritual and
and
out
(if often overlapping)
mosaic
presence.
of roles
as I have
Third,
and sites of social
in structure
complex
and
of site, personnel,
diversity
avoidance
of the term "discipline"
This
to call
chosen
clinical
and text
formal,
disciplinewhere
and research
settings,
institutionalized
is the media/This
suggested,
both
bioethics
action makes
to delineate.
technological
reassures,
implying
ratio
that can be used
order
is academic,
is the hospital
spaces.
A second
bioethics
always,
bioethics
three distinct
occupies
One
novel
the
acting
spectacle,
credentialed
concern,
expertise,
can be
ethical
fundamental
principles
that
the assumption
and
discerned
applied.
Thus bioethics
to
from
ethical
and
social
Internet
years?the
not
but
instead
the bioethical
and
of
experts,
practices,
conglomerate
in both
and public
academic
discourse
BIOETHICS AND THE HISTORICAL
ritualized
and
difficult
function
also
in describing
a
enterprise:
and critical
space.
SENSIBILITY
a number
in which
bioethics
and
of ways
an
and
First,
perhaps
perspective.
analytic
history
might
I would
most
the task of ethical
under
argue,
fundamentally,
recon
historian's
of
cultural
the
should
job
parallel
standing
necessar
seek?if
should
both kinds of practitioners
struction:
I have
specified
share
ily imperfectly?to
ture of choices
understand
as
struc
place-specific
actors.
I
Second,
by particular
structure
of
medi
the
understand
a time-
and
perceived
that we cannot
argue
an understanding
of
histories
of the specific
cal choice without
This was
those choices.
that have created
and society
medicine
would
I hoped
argument
in contemporary
change
the
on
to
illustrate
American
reductionist
increasingly
third, and perhaps most
ics itself. For it is clearly
in my
hospitals
earlier
recounting
of
and my
emphasis
And
of disease.
understandings
we must
historicize
disquieting,
a time-bound
with
enterprise,
bioeth
complex
to the
relationships
in which medicine
society
part
special
41
Policies, and Medicine
Meanings,
of medicine
world
and
to the
larger
in
is nurtured and which medicine
constitutes.
seems
no more
to a
first point,
than a truism
which
My
seem
or
even
will
irrelevant
cultural
historian,
philis
perhaps
on the elucidation
tine to scholars
of ethical
focused
principles
contexts?even
social
and institutional
precise
at
sites.
Moreover,
just such
by abuses
specific
discourse
and
styles of normative
intensify
parallel
on
its emphasis
tradition
of medical
ethics with
from
abstracted
if motivated
such
formal
the historical
the unmediated
one
doctor-patient
the paradigmatic
historian's
point
bedside,
oriented
one
dyad:
vexed
case.
doctor,
From
one
the
patient,
contextu
is al
choice
view,
however,
a
to
in
be
understood
ways
structured,
reality
not
terms
in
of logically
and
situations,
specific
schematically
In
this
coherent
ends.
historical
and
sense,
morally
sociological
not a goal;
is a product,
it is a place-,
and
autonomy
time-,
outcome
the
interaction
of
between
the micro
system-specific
ally
constrained
cosm
of
the
of
and
clinical
encounter
and
and
and
the cognitive
be
elaborated
hardly
larger society
cine. This needs
the macrocosm(s)
institutional
world
at a moment
of
the
of medi
in time when
interactions
find their clinical
limited by man
physicians
to fifteen minutes
and their diagnostic
and
aged care providers
as
are
choices
limited
well.
and
agency
therapeutic
Autonomy
many
context.
There
healing
of bioethical
decontextualized
dilem
understanding
as
I
is definitionally
bioethics
have
mas;
contextual,
argued,
to visible
in the search for particular
its origins
solutions
finding
A decontextualized
in bioethics
is
social
problems.
approach
a matter
not simply
a
act.
it is
of disciplinary
style;
political
constructed
can
and
Discussions
the
reconstructed
in every
be no
of
informed
from
actors?clinicians,
their particular
not
very
consent,
researchers,
social
roles
for
example,
and
patients,
and
individual
that
abstract
"subjects"?
are
identities
in fact mystify
and must
these social
relation
helpful
in
the
de
of those
so,
ships, and,
doing
legitimate
facto authority
institutions
individuals
and
the
At
the
doing
"consenting."17
to underline
risk of seeming
let me take a moment
the
didactic,
way
nates
use of "consent"
as a verb illumi
the colloquial
in
of
routinization
the
of
management
ambiguity
in which
the
42
Charles E. Rosenberg
"autonomy"
and
"beneficence."
of
and
This
is a
usage
syntactical
of
power
representation
comparative
powerlessness,
actor and the object of that actor's
a
actions.
To consent
patient
as
is to act out?and
of
social
legitimate?a
inequality
reality
as to demonstrate
commu
well
the existence
of a self-conscious
of
nity
"consenters"
of
aspect
Iwould
its context
aware
well
of
the
and
ritual
hierarchical
now
this
ethical mechanism.
pervasive
is not only defined
that
bioethics
moreover,
argue,
of use but that it cannot
be self-aware
without
in the past century:
of the history
of medicine
understanding
new
the roles played
and
notions
of disease,
by
specific
by
of specialism
growth
and credentialing,
by
an
of
the
by the siting of the
in a technologically
clinical
rationalized
and struc
or physician's
tured
institution
instead
of the individual
home
office.
This
needs
elaboration.
Bioethics
is, or
point
hardly
a
a
should
social
and
historical
it
for the issues
be,
enterprise,
encounter
seeks
are
to mediate
determining
tics, bioethics
history.
cannot
It becomes
elucidate.
themselves
Without
situate
the
history,
the moral
ethnography,
dilemmas
a self-absorbed
that
of
products
technology,
self-absorbed
and
a
specific,
and poli
to
it chooses
mirroring
and
inevitably
legitimating
all-consuming
to order
it seeks
and understand.
technology
to call programmatically
it is easier
But, as I have
suggested,
to
to
its tasks historically
for bioethics
than
itself and
place
is no simple path to understanding
that task. There
accomplish
the historical
of
bioethics
but rather a variety
of interpre
place
tive
the interpreter's
of view
and the
options,
reflecting
point
a
inherent
elusiveness
of the subject.
The
elicits
enterprise
on the Left, bioethics
of perspectives.
To some critics
diversity
is no more
relentless
than
gears
sounds
a kind
of
into the
sprayed
as to quiet
the
this argu
positions,
of hegemonic
graphite
so
bureaucratic
medicine
Its ethical
of human
pain.
no more
than
are, in terms of social
function,
social and legal criticism,
and are merely
the
of a minority
of ethically-oriented
self-reproaches
physicians.
to this position,
too
Bioethics
focused
moreover,
has,
according
on
instance?on
the
the
visible
problematic
narrowly
plug pulled
offending
ment maintains,
a way
of allaying
or
not
dicted?and
pulled,
on
avoided
the
organism
consideration
cloned
or
of
less
the
inter
cloning
dramatized
easily
Policies, and Medicine
43
bedside dilemmas. And,
finally,
Meanings,
policy debates
and mundane
it is not surprising
that in a bureaucratic
contend,
we
a cadre
have
created
of experts
and a body
of
society
a
to
measure
of
certi
knowledge
provide
soothing
humanity,
fied and routinized.
critics
these
its sophisticated
practitioners
is a humane
bioethics
change
To
hand,
nism
for mediating
technological
of software
that facilitates
kind
on the other
advocates,
an
mecha
agent,
important
and
and
a
change,
of novel
variet
institutional
the adaptation
It is, the argument
states, a genuine
constraint,
a substantive
actor
in a complex
of everyday
renegotiation
medical
bioethics
the con
influenced
has,
practice;
similarly,
duct of clinical
research with
human
and animal
One
subjects.
ies of hardware.
need
and
to the creation
only point
to the
animal
subjects,
of research
existence
for human
guidelines
of institutional
review
to good-faith
to make
a
consent
informed
attempts
an
if
an
unfettered
individual
be
reality.
may
autonomy
unrealizable
the assumption
nevertheless
that
there
is
ideal,
a
a
to
such
contributes
viable
framework
for thinking
thing
about
in itself a resource
transcendent
constitutes
in the
value,
and
boards,
Even
that determine
and constrain
individual
negotiations
complex
a
and institutional
choice.
construc
Bioethics
has also played
tive role in the public
discourse
clinical medicine
surrounding
a
and biom?dical
media
discourse
that is necessar
innovation,
ily
on
focused
as spectacle
yet
particular
problems
our structure of
acts changes
political
perception-altering
most
bioethics
Perhaps
important,
social?and
thus political?assumption
must
be more
transactions.
than
a sum
It promises
the
of
Just
CONTINGENCY,
as the
location,
context.
such
choice.18
the widely
felt
medicine
is and
technical
solutions
impersonal
profit-maximizing
if seductive
elusive
dreams
ultimately
HISTORY,
expresses
that
in
and market
procedures
to human
dilemmas
beyond
or the
choices
of the market
of technological
utopianism.
AND BIOETHICS
three
are location,
in real estate
of value
principles
are
for history
and
location,
context,
context,
they
are implicit
And
in a contextual
irony and contingency
style of analysis; history,
like life itself, is filled with unintended
44
Charles E. Rosenberg
are more
But in one respect
historians
fortunate
consequences.
no
one
than bioethicists:
them to solve emergent
social
expects
on
The
bioethical
the
other
hand,
enterprise,
problems.
origi
to such perceived
seen, as a response
prob
to offer not just analysis
to
of but solutions
as we have
nated,
lems and continues
them.
the most
Yet
profound
are well
We
unsolvable.
of
are, in their nature,
problems
no
that there is
ultimate
solution
such
aware
no way
to explain
for pain and death,
the brutal
randomness
are
with
which
is
distributed.
These
of the
aspects
suffering
human
condition.
Some other
issues are perhaps
less obvious.
is also
There
ties
of
no
social
easy
identity
for example,
themselves
solution,
reenact
to the way
in medical
inequali
care. An
out of our natural
de
grows
yet contradictory
paradox
cure
a
sire for
and care, for technological
human
efficacy with
in one context;
face. But care and cure are not easily
linked
the
other
circumstances
historical
able
achievements
dates,
fragments,
that
also
produce
the
produce
undeni
laboratory's
that
bureaucracy
A parallel
conflict
and distances.
the difference between
the
grows
intimi
out
of
interest as defined by the individual and
a test or procedure
that can
by the collective;
individual
be irrational
from the social system
might
is a health-care
Ours
that has
moreover,
system,
to incorporate
the ability
demonstrated
the criti
as defined
interest
one
benefit
perspective.
consistently
cally and morally
itself. And
system
it an
and make
oppositional
of the
aspect
of
bioeth
irony
of our
quality
is the ultimate
this, perhaps,
ics' history:
the persistent
yet perhaps
illusory
to formulate
to routinize
the humane,
and
desire
in a world
of ceaseless
social
timeless
values
change,
and Utopian
expectations.
laboratory
safeguard
inequality,
ENDNOTES
Esther B. Fein, "Region to get Clinics giving Specialty Care," New York Times,
9 February 1998, Bl.
2Andrea
Gerlin,
"A Venerable
Phila.
Hospital
phia Inquirer, 1 February 1998, Dl;
tute
of
Changes
the Pennsylvania
in Psychiatry,"
Hospital,
see Karl
Philadelphia
Charts
a New
for background
Stark,
Course,"
Philadel
on the sale of the Insti
"Talk
Isn't
Cheap,
Forcing
Inquirer, 14 September 1997, El.
was
3Hahnemann
as America's
founded
tion in 1848, and theMedical
torians
its original
by
premier
the Woman's
is better known to his
Medical
a pioneer
College,
institution founded in 1850. In 1993, the two schools announced
tion
to merge
the
under
of
auspices
and Research
Education,
the Pittsburgh-based
their
they admitted
Foundation;
institu
training
homeopathic
College of Pennsylvania
appellation:
45
Policies, and Medicine
Meanings,
their inten
Health,
two years
Allegheny
first class
later. Cf. Naomi Rogers, An Alternative Path: The Making and Remaking of
Hahnemann Medical College and Hospital of Philadelphia
(New Brunswick
and London: Rutgers University Press, 1998); Gulielma F. Alsop, History of
1850-1950
the Woman's Medical
College: Philadelphia,
Pennsylvania,
(Philadelphia: J. B. Lippincott, 1950).
4Robert
Pear,
Investment
"Medical
to Get
Research
More
An
Government:
from
Money
inHealth," New York Times, 3 January 1998, Al.
Births," New
5Pam Belluck, "Heartache Frequently Visits Parents with Multiple
York Times, 3 January 1998.
6Time, 11 January 1999.
7Which
to
is not
that
say
such
are
variables
not
for
See,
significant.
example,
Charles E. Rosenberg, The Care of Strangers: The Rise of America's Hospital
System (New York: Basic Books, 1987); Morris J. Vogel, The Invention of the
Modern Hospital: Boston, 1870-1930
(Chicago and London: The University
of Chicago Press, 1980); Dorothy Levenson, Montefiore:
The Hospital as
Social Instrument, 1884-1984
(New York: Farrar, Straus & Giroux, 1984).
8See, for example, William Munk,
an Easy
Death
(London:
Euthanasia: Or, Medical
and
Green,
Longmans,
Co.,
9Cf.Allan M. Brandt and Paul Rozin, eds., Morality
London: Routledge, 1997).
10Although
to
it is conventional
twentieth-century
crystallizing
to those
social
see
the
currents
women,
rights?of
anti-authoritarian
that
prisoners,
skepticism
it is equally
in the 1960s
a more
produced
and
sexual
toward
1887).
and Health
movement
bioethics
in Nuremberg,
origins
as a self-conscious
movement
and
(New York and
as
having
conventional
as,
in part,
sensitivity
minorities?and
general
racial
credentialed
inAid of
Treatment
its
it
a response
to individual
as
for
See,
expertise.
late
see
to
an
a first
generation of bioethics history, Albert R. Jonsen, The Birth of Bioethics (New
York and Oxford: Oxford University Press, 1998); David J. Rothman,
Strangers at the Bedside: A History of How Law and Bioethics Transformed
Medical Decision Making (New York: Basic Books, 1991); George J. Annas
and Michael A. Grodin, eds., The Nazi Doctors and the Nuremberg Code:
Human Rights inHuman Experimentation
(New York and Oxford: Oxford
University Press, 1992).
11Ido not mean to imply that medical practice has in fact been invariably humane,
caring,
and
always
been
12Sharon
Begley,
over
selfless
part
of
time, but
the profession's
"Is Everybody
13For an argument
emphasizing
structured
of value
patterns
rather
Crazy?"
a commitment
that
formal
corporate
Newsweek,
the nineteenth-century
see Charles
action,
and
to this
ideal
has
identity.
26
1998,
January
roots
of
such
E. Rosenberg,
51-55.
discipline
No Other
46
Charles E. Rosenberg
On
Gods:
Science
and
American
London: The Johns Hopkins
Social
University
Thought,
2d
ed.,
rev.
and
(Baltimore
Press, 1997).
14Cf.Jonsen, The Birth of Bioethics-, Rothman, Strangers at the Bedside-, George
Weisz, ed., Social Science Perspectives on Medical Ethics (Philadelphia: Univer
sity of Pennsylvania Press, 1990); Albert R. Jonsen, ed., "The Birth of Bioeth
ics," Special Supplement, Hastings Center Report 23 (1993); Ruth R. Faden
and Tom L. Beauchamp, in collaboration with Nancy M. King, A History and
Theory of Informed Consent (New York and Oxford: Oxford University
Press, 1986).
15For a deeply informed guide to this history by an influential participant,
Jonsen, The Birth of Bioethics.
16Personal
Sheldon
communication,
Lisker,
M.D.,
to
the
author,
see
1 February
1999.
17For an
case
illuminating
study,
see Ren?e
R.
Anspach,
Fateful Choices in the Intensive-Care Nursery
London: University of California Press, 1993).
18The
sues
recent
a
media
public
achievement
topic
is a case
of Dr.
in point.
Jack
Kevorkian
Deciding
Who
(Berkeley, Los Angeles,
in making
end-of-life
Lives:
and
is