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David Rothman has written the first formal history of bioethics, Strangers at the Bedside.

Why of all the books that a historian could choose to write did I choose to write about how law and bioethics transformed medical decisionmaking? The answer is very clear. I really was trying to figure out what I was doing as an individual at a medical school. I arrived there not as an ethicist but as someone who was to bring the social sciences and the humanities into the curriculum. The tunnel vision of medical education astonished me.

I wrote Strangers at the Bedside to try to figure out how outsiders came into medicine. It is not in any sense strictly historical. It is not a history of bioethics. I didn't comb the archives; I did not interview most of you in this room.

I was interested in a very different sort of question. I was interested in how a profession that had been so insular, so self-contained, and so responsible to no one except its own members--if that--had undergone the kind of extraordinary transformation that was altogether apparent to me by 1982.

It's quite clear that the changes existed without any real controversy at this point. Decisionmaking had become collective as against individual, formal as against informal. The old days of penciled notes on charts were gone. Outsiders now framed the normative principles, and although I deeply appreciate the existence of medical ethics before bioethics, I still think that is a major transformation.

In the old days of medical ethics written by doctors for doctors and read by very, very few others, medical ethics was, if you will, insular the way the profession was insular. Ultimately, the shift to bioethics meant that outsiders were framing the normative principles. And obviously there was a dramatic shift in the doctor-patient relationship. I may exaggerate it somewhat, but surely the notions of informed consent were unmistakable by 1982--truly a dramatic change.

The key argument I want to raise with you is this: to simply assume that bioethics is the product of changing technology ignores all the interesting questions and doesn't do justice to the complexity of the situation. The technology itself rarely sets off the problem. It's how we feel we have to respond to the technology that ultimately gets interesting.

The second point I want to make is that in the development of bioethics there is an enormous amount of confrontation. I do not think this is a peaceable story. All the reminiscing notwithstanding, I think there was a lot of tension; there was a lot of conflict. And the reason for that conflict is not difficult to understand. The stakes were very, very high. One was talking about professional sovereignty, to the profession that enjoyed the maximum amount of sovereignty.

By no stretch of the imagination did bioethics easily make its way in or, in my context, did outsiders easily make their way into medicine. Think about Walter Mondale in the 1968 hearings with Arthur Kornberg. Kornberg telling him: You're wasting my time. I should be at my lab. Why have you dragged me to Washington? Or Christiaan Barnard coming in and saying: What are you guys doing? Do you want to put American medicine behind South African medicine?

Mondale never forgave Barnard, and he barely forgave Kornberg for those lines. This was not easy stuff. There was distrust, there was distance, there was alienation, there was hostility.

I've written the "sociological facts" that have in fact surrounded this territory. The point I want to make is that ideology was terribly important. (That gets so misused. It's become a form of mud slinging. You can discount ideology all you want, but don't use it in terms of insult.) The ideology of the movement in its first context--and I'm more interested in a movement than a field--had to do with civil rights. That's often invoked. But I want you to go beyond that to appreciate what it means to invoke civil rights.

What it meant was that the patient was understood as a member of a minority. It was as though the patient was a tenant in a housing project, as though the patient was--these models, obviously, with all the feminist language intended--a woman; as though the patient was in some very, very particular way on welfare, powerless.

In the 1960s and early '70s the way a movement expressed itself, for a host of reasons we can't get into now, was through the law. The marriage between bioethics and the law, then, was apt and altogether logical.

There were those who criticized the bioethics movement. Renee Fox and Judy Swazey, for example, were very, very, hard on the bioethics movement, saying it was elevating individual rights above all the other rights; it was infringing on the physician. They took the movement seriously and I think understood it. But what they missed was the extraordinary power that the movement drew from the fact that it was building on this sense of patient as minority and then scaffolding onto it autonomy and all the ancillary issues of consent that go with it.

This movement in its early days had a quite heroic quality about it. I see it becoming older, less heroic, at least from my particular vantage point.
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Title Annotation:Three Views of History
Author:Rothman, David J.
Publication:The Hastings Center Report
Date:Nov 1, 1993
Previous Article:Bioethics and philosophy.
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