Review of Making Modern Medical Ethics

Robert Baker, Making Modern Medical Ethics: How African Americans, Anti-Nazis, Bureaucrats, Feminists, Veterans, and Whistleblowing Moralists Created Bioethics.The MIT Press, 2024.
ISBN 978-0-262-54737-6, Paperback, 317 Pages, $55.00.

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In Making Modern Medical Ethics: How African Americans, Anti-Nazis, Bureaucrats, Feminists, Veterans, and Whistleblowing Moralists Created Bioethics, Robert Baker introduces a counternarrative to traditional histories of bioethics. In the standard histories, such as David Rothman’s Strangers at the Bedside (1991) or Albert Jonsen’s The Birth of Bioethics (1998), bioethics is seen as a mostly American phenomenon arising in the twentieth century as a result of “morally disruptive medical technologies,” such as ventilators, dialysis machines, and organ transplantation (p. ix). These technologies necessitated a reevaluation of medical ethics and the physician-patient relationship and instigated a series of conferences, court cases, legislation, government commissions, and think tanks to address the emerging issues.

Baker seeks to amend this standard history, instead framing the bioethical turn in medical ethics as a moral revolution. And, as he writes, “moral revolutions, like their political and scientific counterparts, are not initiated by establishments but by the dissidents, critics of the established order” (p. x). Thus, in Baker’s account of the birth of bioethics, credit must be given to those people and groups who ushered in the moral revolution that made bioethics possible: the African Americans, anti-Nazis, bureaucrats, feminists, veterans, and whistleblowing moralists referenced by his subtitle.

Baker traces the origin of contemporary bioethics to the European and American response to the Nazi medical atrocities committed during World War II. He dedicates a full chapter to outlining Nazi medical ethics, demonstrating that their belief that the physician’s role was not just to help the patient but to promote the health of all of society led to a twisted perception of morality in which atrocities such as the Holocaust or illicit experiments on prisoners were seen as morally righteous acts. At the Nuremberg Trials held after the war, two American moralists, Leo Alexander and Andrew C. Ivy, were committed to ensuring that such atrocities would never reoccur and were instrumental in developing the Nuremberg Code, a set of ten principles for the ethical use of human subjects in research. This code became a launching point for several later documents by the World Medical Association, including the Declaration of Helsinki, which would be used as the basis for America’s own regulations on human subjects research. In tracing this history, Baker brings attention to several often-overlooked figures in the development of medical ethics and also creates a counternarrative to claims that bioethics arose as a result of American moralism and exceptionalism; according to Baker’s history, bioethics’ origins are international in character, and American bioethics built off of this foundation.

Baker next turns his attention to numerous moralists who questioned the dominant paradigm of research ethics. These include Frances Kathleen Oldham Kelsey, an FDA bureaucrat who was responsible for preventing Thalidomide’s approval in the US and was instrumental in incorporating language from the 1962 draft of the Declaration of Helsinki regarding informed consent into official FDA policy; Maurice Pappworth, a Jewish physician and veteran in the UK who wrote about unethical research practices among both American and British doctors; and Henry K. Beecher, an American physician and veteran who wrote about research ethics and published a famous article in the New England Journal of Medicine calling out some of the most egregious ethics abuses of his day. Baker also dedicates a chapter to the many people who drew attention to the Tuskegee syphilis experiment and the public outcry that arose from its exposure.

Though some might call these moralists whistleblowers, Baker contends that this term is insufficient, for they were not alerting an unwitting public to hidden abuses but rather drawing attention to research that was happening in plain sight. The problem was not that doctors were covertly doing unethical experiments; the issue was that doctors did not see their experiments as unethical in the first place. This forms the basis for the primary claim and throughline of Making Modern Medical Ethics—that the story of bioethics is the story of a moral revolution. Borrowing from Thomas Kuhn’s theory of scientific revolutions, Baker describes the dominant paradigm of early- and mid-twentieth-century medicine as scientistic medical paternalism: the belief that “by virtue of their training and experience and emotional equipoise, physicians alone are the sole rational decision makers, and they alone should determine what is best for a patient’s care” (p. 130–31). Doctors could engage in ethically problematic research without troubling their conscience because, under the paradigm of scientistic medical paternalism, it was up to the doctor to decide what was best. Drawing from the language of Francis Kelsey, Baker portrays physicians under this paradigm as thinking of themselves as “Lords Almighty” and behaving as such (p. 126).

Even as these moralists challenged the paradigm of scientistic medical paternalism in research ethics, other groups challenged the paradigm as it related to patient care. These included many of those whose voices were not valued in the medical system of the time, including women and feminist organizations; minority groups, especially black civil rights activists; the poor who were reliant on Medicare and Medicaid; as well as the elderly. These groups fought for physicians and hospital systems to acknowledge their right to have a say in their own care and won major concessions in the form of a Patient’s Bill of Rights. At the same time, questions arising from the morally disruptive medical technologies more commonly associated with the birth of bioethics were starting to be addressed by people and institutions already familiar in the bioethics literature: the Hastings Center, the Kennedy Center, the government commissions, Beauchamp and Childress’ Principles of Biomedical Ethics, etc. They developed bioethics at the academic and institutional level and created a shared language for “a common secular ethics based on an egalitarian paradigm of transparency and shared decision-making” (p. 189).

As is the case with all revolutions, scientific or moral, a new paradigm had to take the old one’s place. Baker summarizes the new paradigm as one of autonomy, which “emphasized transparency, informed consent, nondiscrimination, and patient’s and subjects’ rights, often justified by invoking concepts valorized by Beauchamp and Childress’s mnemonic synecdoche quartet, ‘autonomy, beneficence, nonmaleficence, and justice’” (p. 189). In Baker’s account of the history of bioethics, it was much more than just disruptive medical technologies that led to challenging the paradigm of scientistic medical paternalism. Those technologies, and the people who thought deeply and critically about their use and adoption, are but one of a much larger group who ushered in the bioethics revolution.

Baker’s Making Modern Medical Ethics is a valuable contribution to the history of bioethics and calls attention to numerous individuals and groups that have been overlooked or downplayed in previous histories. Due to the minority status of many of these marginalized figures, Baker is especially concerned that their contributions be acknowledged in order to challenge the conception that bioethics arose as a predominantly white, male-dominated field. In this, he succeeds. And yet, it is also a source of several tensions within the book.

In the preface, Baker claims to be introducing an “alternative origin narrative” for bioethics (p. xi), and in several places seems to imply that he will be replacing the typically acknowledged founders of bioethics with a new set of heroes and heroines: African Americans, Anti-Nazis, Bureaucrats, Feminists, Veterans, and Whistleblowing Moralists. However, while Baker’s recontextualization of the history of bioethics as a moral revolution is novel, he does not actually negate any of the previous history; he merely works it into his larger narrative of moral revolution and the paradigm shift away from scientistic medical paternalism. In fact, in his own summary statement at the end of the book, he adds back in those groups conspicuously absent from his subtitle: commissions and think tanks. Thus, while “counter-history” or “alternative history” sound flashy, it might be more accurate to say that his work is an expansion of traditional bioethics histories.

Because Baker is so concerned with identifying previously unrecognized contributors to the history of bioethics, there are places where his narrative puts undue emphasis on particular persons or groups without fully substantiating his claims. As one example, Baker is keen to argue that American bioethics was heavily influenced by international precedent, especially the Declaration of Helsinki. He does show how language from a draft of the declaration was incorporated into US law in the 1960s, but he later states that for all of the whistleblowing moralists he considers, it was the Nuremberg Code, not Helsinki, that formed their touchstone for the morality of research ethics (pp. 121–22). These types of questions are raised with numerous figures Baker covers. This is not to deny that they have been overlooked, but it is not always clear whether the scope of their influence matches the importance Baker assigns to them.

Most problematic is Baker’s treatment of past historians of bioethics, Albert Jonsen and David Rothman in particular. In his final chapter, Baker provides a metahistorical analysis of the standard histories of bioethics. Many of his comments are insightful as he unpacks the narratives that Rothman and Jonsen have constructed. However, Baker also engages in much speculation as to why they emphasized or left out certain figures or groups, and he frequently makes unsubstantiated accusations of overt sexism or racism. For example, in discussing the limited coverage Jonsen gives to Frances Kelsey in The Birth of Bioethics, Baker admits that it is possible that Jonsen “never found source material documenting Kelsey’s role”; however, he then goes on to speculate that Jonsen may have assigned her only a limited role because “crediting a female with the initiative to challenge paternalistic male doctors’ scientistic prerogatives as ‘Lord’s Almighty’ is ‘uppity,’ unfeminine, and so, perhaps, not to be mentioned” (197). Baker provides no evidence that Jonsen or other historians held prejudiced views; not including certain people or organizations in their accounts is taken as de facto proof that they must have been deliberately discriminatory.

Baker’s work may not create a full alternate history, but it certainly shows the limitations and oversights of the standard histories. His insights into the nature of moral revolutions and his application of these to the history of bioethics are also valuable and provide many avenues for future study. Making Modern Medical Ethics does not replace the standard histories, but it does succeed in expanding the narratives around the development of bioethics to include many voices that have previously been ignored or marginalized.