Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution by Robert Baker (review)

The history of American medical ethics is a notoriously unwieldy field that encompasses an enormous amount of complex material. No single book can realistically analyze all of its dimensions in a genuinely scholarly fashion. But Robert Baker, one of the nation’s most distinguished professors in that field, has now provided the rest of us with an immensely helpful survey of one of its most important aspects: the evolution of what he terms “the formalized statements of medical morality” (164). Much of Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution traces, in an almost genealogical manner, medicine’s shifting behavioral codes and ethical systems from colonial midwifery oaths and Percival’s “ur-text” on the subject right through to the governmentally legislated standards of the contemporary period. The prodigious amount of research evident on every page of Before Bioethics helps to explain why such a book had never been written before. This is Baker’s magnum opus and it will surely become and remain a standard reference.

Baker contends that those who see the rise of meaningful medical ethics as a recent development are wrong. In his view, the American medical profession had a long history of concern about ethical standards—but those standards were necessarily products of their times. In the early Republic, for example, traditional notions of gentlemanly honor, on the one hand, and the perceived obligations of those who possessed special skills, on the other hand, combined to produce upright behavior among physicians. Transgressors could repent and rehabilitate themselves, or risk being ostracized. In such a world, the main problems facing medical organizations were internal disputes over what was or was not personally honorable, so early medical codes emphasized measures designed to mitigate internal conflicts, or “flytes” as they were called. The responsible treatment of patients—according to the generally accepted social and religious norms of that era—could be assumed among honorable practitioners. While this approach to medical ethics is regarded with skepticism by many modern Americans, Baker offers reasons to take it seriously by tying it to Charles Bosk’s (1979) “forgive and remember” analyses of medical training.

As historical circumstances changed, so did attitudes toward behavioral norms. The proliferation of diverse healers in the wide open medical marketplace of the early nineteenth century forced mainstream American physicians to articulate their own positions more systematically. The most important result, following earlier efforts at the state and local level, was the American Medical Association’s 1847 Code of Medical Ethics. By the last quarter of the nineteenth century, as organized medicine coalesced around licensing laws that generally favored AMA standards, that code attained an all but scriptural status.

Like all scriptures, however, the AMA Code was open to interpretation. In Baker’s view, the interpretations made by AMA strongman Nathan Smith Davis and his allies during that same last quarter of the nineteenth century put medical ethics tragically off its traditional evolutionary tracks. Rather than address ethical controversies at the national level, where they would have caused disruption, Davis allowed separate state and local organizations to decide for themselves how to deal with controversial questions—like whether to recognize black physicians and how to punish transgressing colleagues. The situation worsened when the infamous consultation clause of the AMA Code was interpreted by the Davis group not as an inclusive compromise designed to promote best practice but as a dogmatic absolute with which to persecute perceived heretics, among whom he included even the most educationally sophisticated homoeopaths. Baker labels Davis and his associates “Pharisees,” whose dictatorial and exclusionary rulings all but destroyed an older tradition of flexible and evolving ethical standards that would be appropriate to all physicians.

Internal revolts against Davis’s heavy-handed manipulation of the Code culminated in the AMA’s 1903 Code revisions, which paved the way, in Baker’s view, for more than half...