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David Fox, a founder of the Society for Health and Human Values, has been a careful observer of the development of bioethics.

My chores are these: first, to sketch the six models of history that have been invoked at this celebration. Second, to demonstrate that these models are also useful for understanding another area of our public life that has many similarities with the bioethics movement. And third, I will end by suggesting a new and I think a higher criterion for a theory to explain historical events than most people are familiar with. It is a criterion that looks forward as well as backward.

The six models that I heard were these: one, bioethics has been the soft side of the golden age of medicine, of the expansion of medical power. It's been the conscience, the sensitive side, during a period in which we medicalized practically everything.

Within this broad medicalization of American society, bioethics embraced and brought to bear on medicine the great traditions of moral philosophy, the immediate pressures of civil rights, and concern for minorities of all kinds. And indeed, bioethics also gave the medical profession a wonderful and new set of tools with which to regulate the bad apples, the people within medicine who were behaving in ways inconsistent with the medicalization of practically everything during that wonderful golden age.

The second model is bioethics as a response to technology, to vast elaborations of complexity in diagnostics, in treatment, and in research. In this interpretation of the history of bioethics, technology is a source of problems. There are two variants: one is that technology is a source of problems to be either anticipated or managed. The other is that technology exemplifies the need for a counterreformation in medical thinking or for a restoration to an earlier time.

The third historical explanation, the third model, draws heavily on the tradition of the political economy in our thought. It's the explanation that tries to look at the history of bioethics in terms of supply and demand--supply of what bioethicists could do and a demand for it. There's a political economy of the right and the left, of course. From the right this model emphasizes markets and medicine as a commodity. From the left it emphasizes exactly the same things, but talks more about classes, about the interesting ways in which we observe not whether each of our colleagues has a price, but what it is.

The fourth explanation is what I call the model of great people and great events. Women and men make history. We certainly began that way, as Shana Alexander and Judith Swazey have told us about the Seattle experience.

The fifth model is that the history of bioethics is an assertion of a great cultural tradition during a time of grave and deepening moral crisis for our society.

And the final model, which the people who drifted toward it would probably not identify as a model, is the one that most of us really secretly believe. This is the model that says history is one damned thing after another.

Now let me put this another way and look outward from medicine as I move to the second part of my chore, which is making what to some of you may be an odious, and to others an uncomfortable, and I hope for all of you a provocative comparison: since 1945 the only arena of public concern that absorbed more attention than health care (though not as many of the resources of our society) was the conflict with the Soviet Union and the nuclear arms race. I do not make this comparison lightly.

The history of arms control, I suggest, is to the defense sector of our country what the history of bioethics is to health care. The histories of arms control and health are also roughly parallel in time, events, and constraints. Even though I am hardly an expert on the history of arms control, I detect people who are arguing about very similar models to explain their history.

Let me take you through my models again. For example, is arms control the soft side of the American empire during America's century? Compare the doctrine of limited nuclear war with arguments among bioethicists about avoiding futile heroic interventions. Has arms control been a response to technological proliferation? Can arms control be explained mainly by political economy? Has it been a response to great people and events? Consider the noblest general of them all giving a speech warning against the military industrial complex as he left office in the winter of 1960-61. Consider the great people whose names and exploits we have talked about here.

Now for my point and conclusion. The power of medical knowledge and the necessity of a cold war and arms race were both central aspects of Americans' belief for most of the past half century. Because we believed in the advance of medicine and because we believed in the evil communist empire, we made the people who advanced medicine and those who fought evil doctrines both powerful and wealthier. More important, we let these people dominate a great deal of our public and industrial policy and a great many institutions. And we let them spend a great deal of our money.

In both defense and health through these years there has been a tension between professional and civilian control. Arms control intellectuals and bioethicists have been critically important mediators between the ideologies and the technical fantasies of the professionals on the one hand, and the most adamant and uninformed advocates of civilian control on the other. The mediating role is common to both sectors.

The cold war is ended but not, it turns out, because of actions by the U.S. defense sector or even the scribblings of arms controllers. Will there be a parallel experience in health affairs? Will we learn how to prevent, postpone, or manage illness in ways that challenge the fundamental assumptions that have guided the health industry in which most of us have worked? Will our version of the cold war, our analogue to it, end? Sorry; history can't take you past asking the question.

But as you choose which of the explanatory models you prefer, or invent a new one, ask yourself this question: Will the explanation you choose at least allow for the possibility that our efforts and those of our predecessors in bioethics leave us open to totally unexpected events in the not too distant future?
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Title Annotation:Three Views of History
Author:Fox, Daniel M.
Publication:The Hastings Center Report
Date:Nov 1, 1993
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