Thieves of Virtue: When Bioethics Stole Medicine by Tom Koch (review)

The principal thesis in this book is that bioethics emerged—in the 1960s through the 1980s—under the influence of philosophers who claimed to have universally valid principles that could steer medicine and research to the solution of ethical problems, including even those arising at the bedside of patients. Tom Koch contends that these philosophers and their allied bioethicists “stole medicine” and its traditional values, substituting a philosophical discourse generally inaccessible to the average person. Philosophers thereby refashioned medical ethics in accordance with their vision of a morally and intellectually robust new field. Koch maintains that philosophers have failed to deliver on their promises and that bioethics now needs to move back to the traditional ethics and conceptions of medical care that philosophers snatched away in the rush to a new bioethics.

Ordinarily in a book review a reviewer would report on an author’s arguments for such views, but this book contains virtually no arguments or close analyses of the history of bioethics and the role actually played by moral philosophy and other disciplines in making bioethics what it is today. Koch expresses many opinions about what ails bioethics, but provides virtually no arguments or evidence to support these opinions. He also provides no articulated framework of the values of traditional medical ethics or indeed any normative account, philosophical or otherwise, to substitute for the allegedly failed philosophical foundations of contemporary bioethics. Even in his final chapter, entitled “Complex Ethics: Toward an Ethics of Medicine,” no ethics of medicine is presented—only a litany of complaints about the sins of the founders and foundations of bioethics. Koch also says that he presents an “alternate history” (xiv) to the published accounts by theoreticians and historians in bioethics, but there is no serious history or theory in any of its ten chapters.

Koch rebukes almost everything in bioethics deriving from what he sees as its philosophical architects. But his critique extends to any part of bio-ethics that is incapable of what he describes as the mediation of complex realities, and especially any part of bioethics that “assumes dilemmas of care and noncare can be narrowly defined and then easily resolved within the existing paradigm”; he finds an “artificial simplicity” behind this view (xv–xvii). However, it is somewhat unclear what he takes this artificial simplicity to be, how to understand its scope, and how and where it is manifest in bioethics.

His central complaints of a “thinly principled ethics,” “thinly philosophical method,” and “checklist project” often focus on Beauchamp and Childress’s Principles of Biomedical Ethics, a book Koch sees as at once the most influential paradigm in bioethics, the source of bioethics’ “foundation myth,” and the historical beginning, along with The Belmont Report, of the hijacking of traditional medical ethics (xvii–xix, 9, 119–20, 125–35, 139–64 [esp. 144–46], 225–26, 253–55, 261 [n.4]). Koch’s critiques might have been improved if they had been based on a careful reading of Principles and accurate statements of the arguments found in it, but there is no careful explication of, and no arguments against, what the authors of Principles actually say. Koch’s style is, first, to assail by embroidered summaries that bear little resemblance to what is in the book and, second, to quote critics of the book as if they stated the true views of the authors themselves.

Koch falls prey to one of the most common inaccuracies in interpreting Principles of Biomedical Ethics: He confuses what is actually said in the book with what is commonly reported about it, namely that it is merely a statement of four abstract principles whose content can be reduced to four lines of a slide presentation. His interpretation of the book is a caricature of its theory, methods, and connection to practical judgment. It is a digest so inadequate that it carries no understanding of the theory and its connection to the practical realms of clinical ethics, research ethics, public health ethics, and...