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

This is an important book. The first history of American medical ethics since Donald Konold’s 1962 volume, A History of American Medical Ethics, 1847–1912, Baker’s book represents a major contribution to a much neglected historiography, for despite the ubiquity of bioethics in contemporary media and in medical schools, there has been surprisingly scant attention to the histories of medical ethics and bioethics in the United States. As philosopher-historian Robert Baker argues, the history of medical ethics in America matters for several compelling reasons; it not only illuminates the advent of bioethics (a term first used in print in 1970), but it also continues to inform moral sensibilities and intuitions of physicians as professionals.

The book’s scope is expansive, covering practices of medical ethics and medical morality in the colonial period through the 1970s when bioethics flourished in institutes and medical schools, and bioethicists served on government commissions. So too is Baker’s approach. Whereas Konold focused almost entirely on medical societies and physicians, Baker extends his analysis to encompass medical luminaries such as Benjamin Rush and Worthington Hooker, as well as individuals who rarely, if ever, appear in histories of medical ethics. For example, Baker analyzes the role that midwives played in policing the morality of the birthing chamber. In colonial Massachusetts and New York, midwives swore an oath to be ready and diligent to help any woman in labor, to prevent any deliberate harm to a newborn, and to forestall any woman from pretending to be delivered of a child when she had not given birth. Such oaths, he contends, were the oldest documented evidence of European medical ethics in the colonies. The precepts in the midwife’s oath became law in Puritan Massachusetts in 1696, and were invoked to convict Rebekah Chamblit, a young woman, unmarried and delivered of an out-of-wedlock child, who was executed in 1733 for hiding the dead body of her infant. Midwives’ oaths, and their sophisticated and articulate discussion of fiduciary responsibility, lost currency as female midwifes were replaced by male physicians, whose oaths said virtually nothing about fidelity to patients and responsibility to provide care regardless of ability to pay.

Baker devotes several chapters to physician’s oaths, codes of medical police, and the codes of ethics adopted by medical societies. Unlike more cursory discussions of medical ethics, which typically begin (and end) with the newly formed American Medical Association’s (AMA) adoption of a code of ethics in 1847, Baker carefully analyzes the multiple and overlapping discourses of medical ethics, gentlemanly honor, and professional responsibility in the decades before and after 1846. He examines the varieties of medical licensing, the nature of professional privilege, and the disciplining of errant practitioners. He explores, for example, how the well-known surgeon James Marion Sims fled the United States in 1869 rather than face censure and expulsion by the New York Academy of Medicine and refused to offer a public apology to actress Charlotte Cushman, whose confidentiality he violated by publishing in the popular press details of her disease (a tumor on the breast).

Sims, of course, is notorious in the history of medicine and medical ethics for much more than violations of confidentiality. Sims perfected surgical repair of vesico-vaginal fistula over a period of four years using the bodies of enslaved African American women. Baker carefully rehearses the Sims materials, the evidence from medical journals and his autobiography, and the more recent contemporary indictments of his surgical experiments. In doing so, he offers a more nuanced and thoughtful examination of the context in which Sims conducted his work, and argues that the surgeon’s views about African Americans changed over time. Baker cites as proof for Sims’ changing attitudes the unsuccessful effort...