The Birth of Bioethics: Who is Paul Ramsey?
(by Albert R. Jonsen, 2001 from the preface to the second edition of Paul Ramsey’s ground breaking book The Patient as Person)
The first edition of The Patient as Person appeared in 1970. The book was the published form of the Lyman Beecher Lectures at Yale University, delivered by Professor Paul Ramsey of Princeton University in April 1969. Those lectures and the book that resulted from them can rightly be called the founding preaching and scriptures of the field of bioethics. Bioethics did not exist when Paul Ramsey stepped to the podium on April 14, 1969. The word itself first appeared a year later in an article by Dr. Van Rensselaer Potter entitled “Bioethics: The Science of Survival.” However, the topics that Ramsey addressed in his lectures-the definition of death, care for the dying, organ transplantation, and research with human subjects-were beginning to be discussed and debated, mostly in obscure scientific gatherings but occasionally in public places, such as congressional hearing rooms. In 1962 the Ciba Foundation in Great Britain sponsored one of those obscure scientific conferences that gathered some not-so-obscure figures of science to discuss “Man and His Future.” For several days, Nobel Prize winners in medicine and molecular biology, along with many leading physicians and scientists and a few (very few) humanists, reflected on the prospects for genetics, the neurosciences, and behavioral modification by drugs and surgery. The savants reached no conclusions but expressed concern that scientific progress, desirable as it might be, could lead humankind in unexpected directions, where technical achievement might outstrip moral wisdom. In 1968, in the more public setting of a congressional hearing called by Senator Walter Mondale, the social implications of advances in medicine and the biosciences were reviewed over eight days of hearings. Organ transplantation and genetic research took center stage, with prominent scientists extolling progress and occasionally, together with a few humanists, calling attention to the paradoxical consequences of many advances. Mondale and his fellow senators asked whether some form of public oversight might be advisable. With few exceptions, the scientists and physicians repudiated this idea, with Dr. Owen Wangansteen, one of the nation’s senior surgeons and himself a professor at Mondale’s own University of Minnesota, disdainfully saying, “If you are thinking of theologians, lawyers, philosophers and others to give some direction. . . . I cannot see how they could help. . . . The fellow who holds the apple can peel it best.” So when Paul Ramsey took up the general topic of medical ethics in an era of rapid technological advances, he was addressing an audience that had heard rumors of problems. No one had yet attempted to articulate these problems in a systematic and comprehensive fashion. Ramsey, then, was not the first to speak of these questions as ethical, but he was the first to take a synoptic view.
The Lyman Beecher Lectures were a strange venue for this expression. Established in 1873 to honor a Yale graduate of 1797, the lectures had usually expounded on a theological topic, often on the work of the Christian ministry, before a Divinity School audience. In the past, distinguished speakers, usually from the ecclesiastical world, had delivered impressive lectures from the pulpit of the Divinity School chapel. The 1969 lectures, however, were jointly sponsored by Yale Divinity School and the Yale School of Medicine and were organized as never before. Professor Ramsey lectured four times in the Harkness Auditorium of the Sterling Hall of Medicine. Each lecture was followed by panels in which commentators from medicine, law, theology, philosophy, and elsewhere, responded to Ramsey’s points. Also, each day, seminars were led by prominent scholars from many fields and theologians from the major denominations to expand on the issues Ramsey raised. Thus, the Beecher Lectures were transformed from a solo performance by a prominent church figure to a week of active debate across disciplinary and denominational lines. All of this was a response to a series of questions that were quite novel and unfamiliar to many of the participants.
Paul Ramsey held the post of Harrington Spear Paine Professor of Religion at Princeton University. He received his divinity degree and doctorate at Yale in the early 1940s and had been at Princeton since 1944. Having achieved preeminence in the field of Christian ethics, he wrote extensively about moral philosophy and moral theology in traditions beyond his native Protestantism. He had devoted three books to the moral problem of warfare, a topic that in the 1960s was, to put it mildly, hot. In the mid-1960s, Ramsey was frequently invited to conferences devoted to ethical quandaries in the biosciences, where he spoke cogently and somewhat acerbically about the shallowness of scientists’ moral thinking about abortion and genetics. So when he arrived at Yale for the Beecher Lectures, he was not only a name in theological ethics; he was one of the few proper ethicists who had addressed these questions. The other few were Joseph Fletcher, then Professor of Moral Theology at Episcopal School of Theology in Cambridge, Massachusetts, who had enunciated liberal positions on such topics as abortion, euthanasia, and reproductive technology, and Professor James Gustafson, then Chairman of Yale’s new Department of Religious Studies. Gustafson had written, just a year before Ramsey’s Beecher Lectures, a comment on the growing number of conferences on moral questions in the biosciences: “Such conferences and the papers that are published from them are important at this stage of the discussion . . . but one hopes we can move beyond the conference procedure to a more disciplined, careful, long range way of working in which areas of disagreement can not only be defined but in part at least overcome. What is needed, it seems to me, is interdisciplinary work within universities or centers that have personnel and resources for the arduous tasks of intensive and long-term work.”
Gustafson initiated the invitation to Ramsey. He intended to use the setting of the Beecher Lectures as the beginning of the “interdisciplinary work within universities” that, in his opinion, would come to grips with these looming issues in a systematic way. Gustafson and Ramsey had a long collegial association, and Gustafson, who had himself recently become interested in the ethical questions associated with advances in bioscience, knew that Ramsey had begun to address these issues. Gustafson suggested that the staid Beecher Lectures be transformed into a week of seminars and discussions, involving participants from Yale’s schools of medicine, law, and the arts, and including distinguished scholars from other institutions. He proposed that Catholic theologians and Jewish rabbis, at that time not present in the world of Ivy League scholarship, be invited to participate. Out of these ideas, a unique event emerged: interdisciplinary, interdenominational, interuniversity, designed to begin, even in temporary and transitory fashion, “the arduous tasks of intensive and long-term work” that would bring into the desultory discussions both a disciplined and principled analysis and an informed discourse.
Paul Ramsey not only presided over this unusual event, he had prepared himself for it in an unusual fashion. After receiving the invitation to present the Beecher Lectures, Ramsey determined to speak of these novel topics, not from a speculative viewpoint, but out of an experience of joining scientists and physicians as they actually confront the problems he wished to elucidate. With the cooperation of Dr. Andre Hellegers of Georgetown University School of Medicine, he approached the Joseph P. Kennedy Foundation with a request to support a year of residency as Visiting Professor of Genetic Ethics. During th
e spring semesters of 1968 and 1969, this Princeton theologian joined Georgetown internists, transplant surgeons, obstetricians, and geneticists on their ward rounds and in their conferences. Special conferences were arranged in which medical faculty presented cases for discussion and where Ramsey could both learn the nature of the issues in a practical way, and begin to formulate responses that reflected the mind of a scholarly theological ethicist. As he wrote in the preface to The Patient as Person, “I could put my questions to experts in many fields of medicine, overhear discussions among them, and begin to learn how teachers of medicine, researchers, and practitioners themselves understand the moral aspects of their practice.”
Paul Ramsey was a scholar and a talker. As scholar, he possessed a capacious intelligence and acute analytic skills. He was widely read within and without his tradition. He wrote with eloquence, though some might say, with grandiloquence. As talker, he was articulate and, some might say, incessant. But above all, as talker, he argued. He loved to tear a thesis to tatters, puncture a careless proposition, and reveal the weaknesses in an opponent’s strong points. Although some found him ruthless and intimidating, they frequently followed his line to a sharper, sounder opinion of their own. Some of his fiercest opponents became his closest friends, and many students who cringed under his criticism came away more confident. These qualifications, of scholar and argumentative talker, fit the bill for the Beecher Lecturers as Gustafson conceived them. They also inaugurated a revolution in ethical analysis.
Ramsey chose four topics for his four lectures: “Updating Death,” “Caring for the Dying,” “Giving and Taking Organs for Transplantation,” and “Consent in Medical Experimentation.” A fifth lecture, “Choosing Patients for Sparse Medical Resources,” was prepared but not given, although it is included in The Patient as Person. These topics covered the ground of contentious issues in medical ethics, with the exception of issues related to reproduction and genetics. In each lecture Ramsey reviewed the current state of scientific discussion, stated the moral problems at issue, carefully dissected those issues, and made proposals for structuring a moral argument. As scholar, Ramsey moved beyond a description of the problems to the construction of a moral argument built on certain fundamental concepts and principles and following certain logically dictated steps.
Ramsey opens this project by alluding to a fundamental notion of Judeo-Christian belief: God makes a covenant with humanity, offering steadfast love and fidelity and asking in return that humans manifest to each other the care that mirrors that divine fidelity. That covenant comes to each human, constituting each one as sacred. He says, the “chief aim of [these lectures] is …simply to explore the meaning of care, to find the actions and abstentions that come from adherence to covenant, to ask the meaning of the sanctity of life, to articulate the requirements of steadfast faithfulness to a fellow man. We shall ask, What are the moral claims upon us in crucial medical situations and human relations in which some decision must be made about how to show respect for, protect, preserve, and honor the life of fellow man?” These words appear in the preface of the published edition of the lectures. Despite an assiduous search, I have not been able to locate the actual text of the lectures as delivered, so I do not know how Ramsey introduced these fundamental ideas. The actual chapters open not with the first lecture, on defining death, but with the concluding one, on consent as a canon of loyalty in medical research. That chapter begins with a brief allusion to consent as the expression of a bond of fidelity between persons: fidelity, as Ramsey says, is “normative for all the covenants or moral bonds of life with life.” However, throughout the lengthy text of each chapter, and presumably of each lecture, little more is said about covenant itself. This profound theological notion disappears into a moral analysis that is accessible to readers who might not share or understand its deep implications for human relationships. It disappears but is not gone, for the ideas of both the sacredness of each individual, specifically as individual, and that humans must not only respect that sacredness but care for each one who suffers, needs, or is threatened or diminished, sustain the moral analysis of each topic. This insistence on the sacredness of each individual repudiates the counterpoint utilitarian thesis-that individuals may be subordinated to social uses and communal purposes-which Ramsey contends has crept into medical ethics under the pressure of technological advance.
The Patient as Person exhibits the sharp mind of a thinker who has read the literature in moral philosophy and moral theology, reflected on complex methods of ethical argumentation, and applied them to real moral perplexities. In the years preceding the Beecher lectures, he had taken a step, unusual for Protestant theologians of his day, into the arcane but highly developed world of Roman Catholic moral theology. Such concepts as natural law, the principle of double effect, and the techniques of casuistry (or moral analysis in “the prism of the case,” as Ramsey puts it) had been incorporated, in his own idiosyncratic way, into Ramsey’s mode of moral analysis. In particular, he formulated a tightly reasoned thesis that some ethical principles were “exceptionless,” that is, had an absolute status in moral argument that did not allow for any relaxation. This essay is not the place to follow Paul Ramsey’s ethical theory: suffice to say that he approached medical ethics as a Christian believer with a refined concept of the way Christian belief viewed the moral life and a thesis that the central notions of Christian morality could be applied beyond the doctrinal limits to the moral life of humankind. What the Christian could understand as fidelity to God’s covenant, any human open to honest moral reflection could see as canons of faithfulness between persons in need of each other. Further, Ramsey the Christian ethicist brought to medical ethics a set of finely and firmly argued principles and methods for moral analysis. As he said in the preface to The Patient as Person, “medical ethics cannot remain at the level of surface intuitions or in an impasse of conversation stoppers. At this point there can be no other resort than to ethical theory.”
Using these talents, Paul Ramsey worked out the first explicit reasoning on several much-discussed questions. He prefaces his particular topics with the assertion that “medical ethics today must indeed be ‘casuistry’; it must deal as competently and exhaustively as possible with the concrete features of actual moral decisions of life and death and medical care.” Each lecture then addresses several actual cases, subjects the moral propositions about them to criticism, and emerges with a reasoned critique. Ramsey offers a sustained commentary on the efforts to update the definition of death, uncovering major confusions between death, immanent dying, and permanent coma in such prestigious proposals as the Harvard Report on the Definition of Death, which had been issued two years before. He provides the first detailed argumentation about discontinuing life support, expanding with exquisite refinement the traditional Roman Catholic doctrine of ordinary versus extraordinary means of sustaining life. He refutes utilitarian justifications of taking human organs for transplantation without consent of the source of those organs. He erects a monumental argument that research involving human beings can be ethical only with the consent of the experimental subject and can never be justified only by contributions to the common good. In this latter argument he encounters one of his “exceptionless rules,” namely that proxy consent for research interventions
can never be ethically justified, thus ruling out, without exception, research on all who cannot give consent, including children.
The work of an ethicist is to articulate structured arguments of principles, facts, and conclusions, and apply these to particular topics that arise in the moral life of individuals and society. Ramsey’s Beecher Lectures did this for the novel topics posed by the advancing biomedical sciences. In so doing, he began to create a discipline. An academic discipline is a recognized body of theory, principles, and methods relevant to a subject matter, which can be taught to students and elaborated by colleagues. Disciplines appear around inquiry, merge as inquiry grows more complex, and fade as inquiry moves into different paths. Ramsey was a scholar in one such teachable body of fact, theory, and method, that is, theological ethics (some would say, of course, that theology has no facts, but leave that aside). When Ramsey began the Beecher Lectures there was no discipline of bioethics, or even medical ethics. When he finished, there was the inkling of a new discipline. Inkling only, for as others followed Ramsey, and as Ramsey himself continued on, the theories, principles, and methods took different shapes. Different approaches were tried over the next decade, but clearly, the move to formulate a discipline that could comprehend the moral issues of medicine and the biosciences was under way. When Dan Callahan wrote his essay “Bioethics as a Discipline” in 1973, he assumed that a discipline was emerging from the discussions and debates, and when James Childress and Tom Beauchamp wrote Principles of Biomedical Ethics in 1979, all the apparatus of a discipline was in place.
By that time, there was not much left of Ramsey’s theory of covenant. His reliance on the “sanctity of the individual” was converted, or diluted, he would say, into the more secular respect for the dignity of persons. His rich canon of fidelity was reduced to the bare concept of informed consent. His casuistic method remained an integral piece of bioethical discourse. His arguments about “only caring for the dying” and discontinuing life support for the imminently dying remained and were worked over by many subsequent contributors. His thesis about the gifting of organs as distinguished from harvesting without consent had become public policy. His view of experimentation as “joint venturing in the common cause of cure,” in which the venturers-investigator and subject-are bound by a consensual bond remained an ideal only feebly translated into practice by federal regulations requiring peer review and informed consent to perform research with human subjects. What Ramsey spoke about in 1969 had become, by 1979, the subject matter of an evolving discipline that by the mid-1970s was commonly designated “bioethics.”
Ramsey was not only scholar but talker. He had prepared for the Beecher Lectures by taking the unusual course of spending two full semesters talking with doctors and scientists at Georgetown University School of Medicine. Although titled professor, he made himself a student who asked questions and ventured answers at the “biweekly conferences arranged for his instruction.” The Beecher Lectures allowed him an hour on four successive days to talk in the scholarly mode of a formal lecture. During that hour, he could lay down the framework of a disciplinary analysis by stating principles, arguing cases, and drawing conclusions. Then he had to enter into debate with other scholars on responder’s panels. Ramsey’s words about the definition of death had to meet the words of Harvard University’s Dr. Henry Beecher, who had composed the Harvard Definition of Death document. His comments about organ transplantation faced those of Rabbi Seymour Siegel of the Jewish Theological Seminary, representing a tradition that repudiated autopsy. His arguments about allowing the dying to die confronted the deep convictions about personal autonomy associated with Dr. Jay Katz of Yale Law School. There is no way to know what was actually said in those post-lecture comments: no record exists. But given Ramsey’s propensity for strong argument and the reputations of the responders, we can imagine that the discussions were vigorous.
Among the respondents was Father Richard McCormick, a Jesuit moral theologian of rising provenance. McCormick heard Ramsey defend the thesis that children could never be the subjects of experimentation. What the Catholic scholar said on that occasion, we can not know. (Father McCormick died in early 2000.) However, six years after the Beecher Lectures, McCormick debated Ramsey on this issue before the National Commission for Protection of Human Subjects of Biomedical and Behavioral Research, where the Protestant and the Catholic ethicists formulated opposing views, with clearly articulated arguments to support them. This allowed the commission, of which I was a member, to evaluate this most difficult problem and carefully formulate a public policy response that respected essential values, although it rejected Ramsey’s contention of an exceptionless rule in this matter.
The debate before the National Commission was one manifestation of a second contribution to bioethics that Ramsey’s Beecher Lectures inaugurated. As we noted above, an array of discussions and debates took place around Ramsey’s magisterial lectures. Not only were there three respondents to each lecture but also, on three days, seminars were held from 10 a.m. to 4 p.m. at both the Divinity School and the School of Medicine on the topics of medical ethics. Again, distinguished scholars met with students in law, medicine, and divinity to explore the issues. Callahan’s essay, “Bioethics as a Discipline,” had suggested that this new discipline should consist not only of logic, consistency, careful use of terms, and rational justification -the standard stuff of disciplinary thought-but also of a rich and wide-ranging discussion, “a continuing, tension ridden dialectic . . . kept alive by a continued exposure to specific cases in all their human dimensions.” The very structure of the Beecher Lectures of 1969, as devised by Professor James Gustafson, fostered that discussion across disciplines. Never before had the staid Beecher Lectures been so structured; never before had the measured eloquence of the famed speakers been thrown into the turmoil of debate. But bioethics began as discussion and debate, in many small circles, and gradually widened into a discourse in which many persons participated. During the 1970s, governmental commissions were established to debate certain issues and recommend public policy. Committees were appointed in research institutions to review protocols that recruited human subjects. Hospitals initiated ethics committees to clarify policy on life support. Courts heard arguments on life-and death cases. Courses were offered in many schools of medicine and schools of nursing, in some law schools, and even in undergraduate colleges. The media began to notice these discussions and, more and more frequently, articles appeared in the press and stories on television. Legislatures voted on bills about research, death, and genetics, and electorates were offered initiatives about life and death. A discourse was under way in corners where the proprieties of academic disciplines gave way to more impassioned debate.
At the same time, this wider discourse has been well informed by the discipline. The commissions and committees produce documents and regulations formulated with the principles of the discipline in the background. The courses use texts written by scholars in bioethics. Even the courts echo disciplinary conclusions in their obiter dicta. The media, undisciplined as it is, invites disciplinary scholars to comment, and the “ethicist” has become an obligatory face or voice on page and screen. The discourse about bioethics runs alongside, and sometimes overtakes, the discipline of bioethics. The Beecher Lectures of 1969 pre
visioned this dual development, and the lost words of the commentators and the seminar attendees are as important as the preserved words of the lecturer published in The Patient as Person.
I titled this essay “The Structure of an Ethical Revolution.” A few years before the Beecher Lectures, Thomas Kuhn published an epochal book with an analogous title and a contentious thesis about the ways science advances from paradigm to paradigm. I abstract from Kuhn’s thesis and allude to his title only to make one point: the paradigm of doing ethics was changed radically by Ramsey’s Beecher Lectures. The previous paradigm, in place from time immemorial in Western culture, had been the thoughtful person observing the moral life of his or her society, and elucidating a series of reasoned propositions about the ways in which the moral life should be conceived and lived. Of course, also from time immemorial, persons have argued among themselves in church meetings, in legislative halls and in saloons, about the strictures and ideals of the moral life. Still, the creation of a discipline of ethics has not generally been in close contact with the public discourse about morality. Bioethics must touch the emotional and affective sources of moral dilemmas as well as elucidate the rational and intellectual facets of problems. It must also work with the accurate data of science and the factual features of events and institutions, as well as with theory and principle. Bioethics is, and must be, both discipline and discourse, and the Beecher Lectures, in their intellectual content and in their programmatic structure, set the direction.
Paul Ramsey died in 1988. What if his imposing figure were standing here today, thirty years after he mounted the podium in the Harkness Auditorium? What might he say about bioethics, the discipline and discourse to whose inauguration he contributed? During the years after the Beecher Lectures, Ramsey wrote much about bioethics, touching on many of its topics with cogent remarks. He took stands against involuntary euthanasia, particularly of the severely ill newborn. He continued to oppose research with children. He reiterated his opposition to certain forms of genetic engineering and reproductive technology. But, if he examined the vital field of bioethics today, he would be dismayed to see that it remains conflicted about its ethical foundations. He would decry the wavering about principle and cases, a problem that he probably felt he settled in his 1976 treatise, Deeds and Rules in Christian Ethics. He would be appalled to see the intricate structure of ethical argument, with its exceptionless principles, collapse into a principle of autonomy, which, as he once said, merely “enthrones arbitrary freedom.” He might be amused and somewhat sardonic about the scramble to collect arguments against human cloning, an issue he put to rest when cloning was merely a dream. He would probably be sad to discover that the strong religious voices of early bioethics are now drowned out in an essentially secular discourse.
Ramsey resuscitated might utter a harsh judgment about bioethics as a discipline, but it is certain that, were he here, he would plunge into bioethics as a discourse. Ramsey the talker would have something cogent to say about stem cell research, fetal cell transplantation, genetic testing and therapy, physician-assisted suicide, and random clinical trials in third-world countries. He would find it exhilarating to plunge into the new territories open to bioethics, those issues of environmental health and safety, genetically engineered foods, and ecological protection that move bioethics from the medical world into the wider world of the relation between humans and the biosphere. He would certainly relish participation in the debates about evolutionary psychology, sociobiology and psychoneurology.
Paul Ramsey would be pleased to see that Yale University has initiated an Interdisciplinary Bioethics Project to pursue all these questions in an interdisciplinary manner. He would echo today what he said in the preface to the Beecher Lectures, “[These lectures are] a plea for fundamental dialogue about the urgent moral issues arising in medical practice. . . . To take up the questions of medical ethics for probing, to try to enter into the heart of these problems with reasonable and compassionate moral reflection, is to engage in the greatest of joint ventures: the moral becoming of man. This is to see in the prism of medical cases the claims of any man to be honored and respected. So might we enter thoughtfully and actively into the moral history of mankind’s fidelity to covenants. In this everyone is engaged.”
Albert R. Jonsen 2001
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