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Kennedy Institute of Ethics Journal Vol. 17, No. 1, 322 2007 by The Johns Hopkins University Press
Robert Baker and Laurence McCullough
Medical Ethics Appropriation of Moral
Philosophy: The Case of the Sympathetic
and the Unsympathetic Physician
*
ABSTRACT. Philosophy textbooks typically treat bioethics as a form of applied
ethicsi.e., an attempt to apply a moral theory, like utilitarianism, to controver-
sial ethical issues in biology and medicine. Historians, however, can fnd virtually
no cases in which applied philosophical moral theory infuenced ethical practice
in biology or medicine. In light of the absence of historical evidence, the authors
of this paper advance an alternative model of the historical relationship between
philosophical ethics and medical ethics, the appropriation model. They offer two
historical case studies to illustrate the ways in which physicians have appropri-
ated concepts and theory fragments from philosophers, and demonstrate how
appropriated moral philosophy profoundly infuenced the way medical morality
was conceived and practiced.
P
hilosophically trained bioethicists take it as an article of faith that
applied ethical theory infuences medical ethics. Bioethics textbooks
genufect before this faith by opening with short selections from Aris-
totle, Kant, and Mill, or with discussions of deontology and utilitarianism.
Medical ethics is presumed to be a matter of applying moral principles
drawn from philosophical theories, like utilitarianism, to practical moral
concerns arising in medicine. Peruse the Encyclopedia of Bioethics and
one will fnd such comments as: Thoreau [on] civil disobedience [is]
only [one] of countless historical examples of what we would call applied
ethics. . . . [B]ioethicists . . . and other applied ethicists typically look to
*
This article is adapted by the authors from Robert Baker and Laurence McCullough, The
Discourses of Philosophical Medical Ethics, forthcoming in A History of Medical Ethics,
edited by Robert Baker and Laurence McCullough, Cambridge University Press, 2007.
Reprinted with permission of Cambridge University Press.
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philosophical ethics, to substantive theories like utilitarianism and virtue
ethics and Kantianism . . . for some enlightenment on practical issues
(Slote 1995, p. 726; 2004, p. 802).
Historians and philosophers who have tested the applied ethics model
against the history of medical ethics have found it wanting. Remarking
on the curious disconnection of medical ethics from contemporary ideas
about individual and social behavior, historian Daniel Fox (1979, p. 18)
dismisses as balderdash the notion that philosophical theories have infu-
enced medical ethics. Philosopher Robert Veatch found that philosophy
has infuenced medical ethics only during a few brief periods17701800
and 1970 to the presentwhen doctors entered into a meaningful dia-
logue with philosophers. Aside from these periods, however, the histo-
rians have it right: doctors dealing with medical ethics did not dialogue
with philosophers or apply moral philosophy to moral issues in medicine
(Veatch 2005).
Like Slote and almost everyone else in the feld, Fox and Veatch pre-
sume an applied ethics model of the relationship between philosophy and
medical ethics. We refected on this model while writing a chapter for A
History of Medical Ethics (Baker and McCullough 2007) and found that
although moral philosophy has signifcantly infuenced medical ethics, the
nature of its infuence is not that envisioned on the applied ethics model.
In this paper, we offer an alternative model of the relationship between
philosophy and medical ethics, the appropriation model, and we explore
its implications for bioethics.
APPROPRIATING MORAL PHILOSOPHY FOR PRACTICAL ETHICS
The English physician and philosopher Thomas Percival (17401804)
appears to be the author of the earliest known published use of the expres-
sion practical ethics. In his preface to Medical Ethics, Percival (1803, p.
5, referring to Gisborne 1794) characterizes a book by Thomas Gisborne
(17581846), an Evangelical Anglican minister and political philosopher,
as the most complete system, extant, of Practical Ethics. Percival,
who was nearly blind when he dictated the preface to his son, probably
misremembered Gisbornes usage, which was not practical ethics but
applied moral philosophy (Gisborne 1789). Percivals felicitous misre-
membrance, however, is useful in illustrating some differences between
applied ethicists like Gisborne, who self-consciously apply a philosophi-
cal theoryin the case in point, Lockes social contractand practical
ethicists who appropriate philosophical concepts and theory fragments
for use in practical contexts.
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As the expression itself connotes, applied ethics involves an attempt
to apply the precepts, principles, and rules of moral philosophy to some
practical context; appropriation, in contrast, is about adapting concepts
and theory fragments to practical contexts. What is the difference? Since
appropriation involves recontextualizing philosophical concepts and the-
ory fragments to adapt them to practical purposes, fdelity to the original
source is less relevant than the impact of the adaptation on practical mo-
ralityi.e., whether the appropriation provides new conceptual resources
that prove felicitous in resolving practical moral issues. On the applied
ethics model, in contrast, fdelity to philosophical theory is highly relevant:
if an applied ethicist or a practitioner alters a concept or a principle in
applying it, the ethicist or practitioner has made a mistake. On the
applied ethics model, Percival can be faulted for getting Gisbornes usage
wrong; on the appropriation model, if one fnds the concept of practical
ethicsthe concept of an ethics of practice and practitionersfruitful,
Percivals misremembrance matters not one fg. What matters is that the
appropriated concept illuminates issues and provides conceptual resources
useful in resolving practical diffculties.
To probe the differences between applied and appropriated ethics more
deeply: applying anything, whether principles or paint, is not particularly
creative. The introductory snippets from iconic philosophers and the prcis
of canonical moral philosophy in the introductory sections of textbooks
thus refect the inherently self-marginalizing view that the important and
innovative aspect of applied ethics resides in moral philosophy and moral
philosophers, and not in the applications of the theories that constitute the
rest of the volume. Those who merely apply philosophical theoriesap-
plied ethicists, including medical ethicists and bioethicistsare thus un-
imaginative and of little philosophical, intellectual, or historical interest.
On the appropriation model, in contrast, ethical innovation is driven by
the creative adaptation of philosophical conceptions and theory fragments
for practical purposes. On this model, the source of innovation is the ap-
propriator, the appropriation process, and the impact of the appropriation
on moral practice. The focus thus naturally turns to fgures like Percival,
to the process by which he appropriated and adapted concepts to practical
purposes, and to the impact of his conceptual innovations on the received
morality of medicine and on medical practices (discussed in detail in
Baker and McCullough 2007). Thus, whereas the applied ethics model
emphasizes the signifcance of the moral philosopher, trivializing the role
of the applied ethicist, the appropriation model emphasizes the role of the
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appropriating practitioner, the medical ethicist, or the bioethicist as ethical
innovator, moral reformer, or, in some cases, moral revolutionary.
Although we cannot explore this aspect of our analysis in this paper, we
should remark that practitioners and practical ethicists typically turn to
moral philosophy either to defend or to change received moral norms and
justifcatory ethical paradigms. Moral reform involves the reinterpretation
of accepted moral concepts to justify new virtues and/or moral norms.
Moral revolutions, like the medical ethics revolution of the late eighteenth
and early nineteenth century and the bioethics revolution that started in
the 1970s, involve the appropriation of philosophical concepts or theory
fragments to create new ethical paradigms that justify moral norms that
confict with conventionally accepted moral concepts and norms. In this
paper, we provide two short case sketches, one of a moral reform, the
other of a moral revolution. Before we turn to these cases, however, we
need to discuss some methodological matters.
METHODOLOGICAL MATTERS
We have appropriated the notion of assessing philosophical infuence
in terms of concepts and theory fragments, rather than in terms of entire
theories, principles, or rules, from the philosopher Hans-Georg Gadamer
(19002002; see Gadamer 1996), to whom we also are indebted for the
notion of the long horizon along which the written word can exert
infuence a concept that suggests that words penned by an ancient phi-
losopher, like Plato (427?347 BCE), can impact future generations even
when the face-to-face dialoguethe focus of Veatchs analysisis impos-
sible. We have also appropriated historian of science I. Bernard Cohens
four-stage model of the transformation of innovative ideas into conven-
tional wisdom (Cohen 1985). On Cohens four-stage model, innovation
commences when an innovator toys with a new concept or theory. In stage
two, the innovator commits to the concept or theory. In stage three, the
concept or theory is broadly disseminated. In the fourth and fnal stage,
it is widely accepted as the received view or conventional wisdom.
We believe that philosophical concepts and theory fragments typically
are introduced into medicine and medical morality by an appropriator
who recontextualizes and transforms concepts and fragments, giving
them a new sense specifc to the discourse of medicine, medical science, or
medical ethics. After this medical/scientifc transformation, these originally
philosophical concepts and discourses become disseminated, not as phi-
losophy, but as elements of the discourse of medicine or science. Further
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transmission of the concept or fragment moves laterally, from practitioner
to practitioner, so that philosophical origins are forgottengiving rise to
the phenomena underlying Foxs disconnection hypothesis. Concepts and
fragments originally adapted from philosophy become embedded in the
everyday discourse of practice and are accepted as conventional. There is
one interesting exception to this pattern: concepts or discourses may be
reconnected with their philosophical origins if they prove controversial.
Proponents of the controversial concept or discourse will then reassert its
original philosophical origins to valorize or legitimate it.
To adapt Cohens model to our purposes, we analyze the linguistic tracks
left by a concept or theory fragment as it travels across Cohens four stages.
Conceptual innovation (stage one) requires new terminologye.g., applied
moral philosophy, practical ethicsor a new way of interpreting older
terms or usagese.g., sympathy. Thus, stage two of conceptual innova-
tion becomes evident when novel usages become integral to the innovators
idiolecti.e., the innovators way of using language. Stage three involves
the spread of a usage from the innovators idiolect to become a dialect used
by some larger group or subgroup within the community. If a usage fails to
spread beyond innovators idiolect, the concept it embeds will have failed
to move to the third stage. Gisbornes use of applied moral philosophy
and Percivals use of practical ethics, for example, never spread to other
speakers. Thus, although their usages anticipate later concepts of applied
and practical ethics, we have no evidence that these later concepts actually
derive from Percivals or Gisbornes usages. Finally, in stage four, a concept
can be considered the conventional or received view if the discourse that
embeds it becomes integral to medical/scientifc discourse more generally,
perhaps even becoming a standard usage in the wider language.
Consider, as an illustrative example, a case that every philosopher in
bioethics takes as indisputable: the dissemination of the philosophical
concepts of autonomy and respect for persons from the philosophical
works of Immanuel Kant (17241804) to daily conversation in clinics and
laboratories. The appropriation of Kantian concepts to the practical ethical
issue of protecting the human subjects of scientifc research began (stages
one and two) in such infuential works as theologian Paul Ramseys Patient
as Person (Ramsey 1970). Kantian usages became widely disseminated
(stage three) in the 1980s through the Belmont Report (National Commis-
sion for the Protection of Human Subject of Biomedical and Behavioral
Research 1979) and the Principles of Biomedical Ethics (Beauchamp and
Childress 1979). These publications became the source from which the
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usages were disseminated and became integral (stage four) to the everyday
discourse of bioethicists, clinicians, and researchers. By the mid-1990s, the
American Medical Association (AMA) could use the term autonomy
in documents addressed to working medical practitioners without further
explanation. Thus, the AMA wrote in its Code of Ethics: The principle of
patient autonomy requires that physicians should respect the decision to
forego life-sustaining treatment who possesses decision-making capacity
(AMA [1847, 1994] 1999, 2.20, emphasis added; AMA 2007, 2.20; for
a similar empirically-based approach to analyzing conceptual infuence,
see Evans 2002).
This method of using language to track philosophical infuence permits
the analysis of the creative transformations required for innovation in
practical ethics. In the case of autonomy, as the philosophically trained
bioethicist Judith Andre (2002, p. 53) remarks in her perceptive semi-
autobiographical study of the feld, Bioethics as Practice, Nonphiloso-
phers understandably assume that autonomy as it is used in bioethics is a
direct unaltered borrowing from the language of philosophers. Most phi-
losophers know that it is not. On the applied ethics model, the discrepancy
between the philosophical and bioethical use of autonomy is treated as
an error: silly bioethicists, remarks the applied ethical theorist, they
dont understand what autonomy really means! On the appropriation
model, transformations in the process of adapting philosophical concepts
are the core of innovation in practical ethics. It simply beggars belief to
assume that the scholars involved in drafting the Belmont ReportTom
Beauchamp, James Childress, Albert Jonsen, Karen Lebacqz, Robert
Levine, Stephen Toulmin, and LeRoy Walters, to name a fewcommitted
a sophomoric error in using Kantian terminology. It is more reasonable
to assume that the Belmont authors adapted Kantian conceptions to the
problem at hand. They transformed the original meaning of the term
autonomy in an effort to justify a new regulatory apparatus that could
protect vulnerable populations, like those at New Yorks Willowbrook
State School for the Retarded, many of whom were not autonomous in
the Kantian sense. Analyzing the linguistic variation involved in adapting
Kantian language for the practical purposes of the Belmont Report and in
the Principles of Biomedical Ethicsand the subsequent dissemination of
new usages from bioethics to the bedside and the benchsidethus offers
a window on the processes of adaptation and dissemination integral to
successful innovation in practical ethics.
In the sections that follow we present two case sketcheseach exam-
ined in more detail in Baker and McCullough 2007to illustrate the
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appropriation model of the infuence of moral philosophy on practical
ethics and morality: a case of moral reform and a case of moral revolution.
Both cases turn on the concept of the sympathetic physician. The frst case
involves the creation of this concept by a physician-philosopher who, in
an effort at moral reform, appropriates the concept from the discourse of
contemporary moral philosophers. The second case involves a physician
who appropriates theory fragments from two iconic philosophers, Plato
and Nietzsche (18441900), in an attempt at moral revolution that suc-
cessfully rejected the ethical ideal of the sympathetic physician and the
moral norms and virtues associated with that ideal.
CASE SKETCH: THE IDEAL OF THE SYMPATHETIC PHYSICIAN
The ideal of the sympathetic physician is so deeply embedded in con-
ventional medical morality and popular culture (More 1994) that it has
come to be thought of as self-evident, universal, and ahistoric lacking a
moment of invention or introduction. In fact, the ideal of the sympathetic
and caring physician attending to the needs of a trusting patient originates
in the Scottish Enlightenment of the eighteenth century. Nothing in the
extensive literature on the character and virtues of physicians that precedes
the Scottish Enlightenment embraces this ideal.
The ascendancy of the virtue of sympathy is due largely to the writ-
ings of physician-philosopher John Gregory (17241773), who created
the ideal while a Professor of Medicine at the University of Edinburgh
(17661773). Gregory had taught moral philosophy previously at Kings
College, Aberdeen, and in 1758 had founded the Aberdeen Philosophi-
cal Society with his cousin, the philosopher Thomas Reid (17101796).
The society met and discussed the ideas of, among others, the moral
sense theorist, David Hume of Edinburgh (17111776), with whom the
Wise Club corresponded. Gregory was, in short, both a physician and a
philosopher, an eighteenth-century prototype for the twentieth-century
M.D.-Ph.D. bioethicist (Gregory [1770] 1998; [1772] 1998; Haakonssen
1997; McCullough 1998; Spiro 1993; Veatch 2005).
Gregory shared with Scottish philosophers the view that morality was
grounded not in reason or the intellect, but in the human capacity of
sympathy with ones fellowsi.e., our ability, in some sense, to feel the
suffering of others. Hume ([1739] 2000, p. 368) explains our feelings of
sympathy by asking readers to imagine themselves observing
. . . any of the more terrible operations of surgery, tis certain, that even be-
fore it begun, the signs of anxiety and concern in the patient and assistants,
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woud have a great effect upon my mind, and excite the strongest sentiments
of pity and terror . . . And consequently these give rise to our sympathy.
Sympathy was the basis of human morality, moreover, because, unlike
impotent intellectual refection, it could motivate action.
For supposing I saw a person perfectly unknown to me, who, while asleep
in the felds, was in danger of being trod under foot by horses, I shoud
immediately run to his assistance; and in this I shoud be actuated by the
same principle of sympathy . . . tis evident, that, in considering the future
possible or probable condition of any person, we may enter into it with so
vivid a conception as to make it our own concern. (Hume [1739] 2000,
p. 248)
Gregory, too, believed that sympathy, rather than reason or the under-
standing, was the basis of human society and morality. He characterized
sympathy as a
. . . distinguishing principle of mankind . . . [that] unites them into societ-
ies & attaches them to one another by sympathy and affection . . . This
principle is the source of the most heartfelt pleasure, which we ever taste.
It does not appear to have any natural connexion with the understanding.
(Gregory 1759, p. 7; 1765)
When Gregory began lecturing on medical ethics to his medical stu-
dents in Edinburgh in the late 1760s, he employed concepts and forms
of discourse common to the parlance of Aberdeen Philosophical Society
to discuss the character and moral qualities of a good physician. In the
medical school context, this discourse was idiolectic: none of the other
professors had used the language of Scottish moral philosophy in their
lectures (McCullough 1998, pp. 17882). Note that Gregory made no
recourse to applied ethics pedagogy. He did not lecture on Scottish moral
philosophy; he did not explain the philosophical source of his concepts.
He did not apply principles of Scottish moral philosophy to medicine, he
simply appropriated concepts, adapting them to medical contexts, trans-
forming them into a medicalized morality directly comprehensible and
practically useful to medical students.
The most oft-cited passage in Gregorys lectures addresses the moral
qualities peculiarly required in the character of a physician.
The chief of these is . . . that sensibility of heart which makes us feel for the
distresses of our fellow-creatures, and which, of consequence, incites us in
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the most powerful manner to relieve them. Sympathy produces an anxious
attention to a thousand little circumstances that may tend to relieve the
patient; an attention which money can never purchase: hence the inexpress-
ible comfort of having a friend for a physician. Sympathy naturally engages
the affection and confdence of a patient, which, in many cases, is of the
utmost consequence to his recovery. If the physician possesses gentleness
of manners, and a compassionate heart . . . the patient feels his approach
like that of a guardian angel ministering to his relief; while every visit of a
physician who is unfeeling and rough in his manners, makes his heart sink
within him, as at the presence of one, who comes to pronounce his doom.
Men of the most compassionate tempers . . . acquire in the process of time
that composure of mind so necessary to the practice of physick. They can
feel what is amiable in pity, without suffering it to enervate or unman them.
(Gregory [1772] 1998, p. 170)
To reiterate, the available lecture notes show no evidence whatsoever
that any other lecturer at Edinburgh or Glasgowor Cambridge or Ox-
ford or London for that matterused the discourse of Scottish moral
philosophy to characterize the moral qualities peculiarly required in the
character of a physician before Gregory.
1
No one else had designated the
chief virtue of a physician a sensibility of heart which makes us feel for
the distresses of our fellow creatures. This notion was unique to Scottish
moral philosophy and Gregory , ingeniously, had medicalized it in an effort
to reform the received medical morality (see McCullough 1998).
In adapting the concept to medicine, however, Gregory also had trans-
formed it. As he observed in his 1759 note (quoted previously), for the
Scottish moral philosophers sympathy underlay all human morality and
all virtues. It is not specifc to any endeavor. In his 1770s medical lec-
tures, however, Gregory transforms it into a specifc virtue superlatively
applicable to physicians. On an applied ethics model this something akin
to a category mistake; on an appropriation model, this transformative
adaptation is a paradigm of innovation in practical ethics.
Gregorys innovative conception of the virtues of the moral physician
met with a mixed reception, in part because, as his use of the term un-
man suggests, the popular culture of the period regarded sympathy as an
unmanly, feminine virtue (see Gregory [1772] 1998, pp. 17072). Yet,
despite the sometimes-hostile initial reaction to Gregorys characterization
of the good physician as humanely sympathetic, by the mid-nineteenth
century this characterization was adopted by admiring medical school
lecturers like Michael Ryan (18001841) of the University of London and
Sir Benjamin Collins Brodie (17831862), surgeon to Prince Albert and
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President of the Royal Society. In an 1843 address to a medical school
class, Brodie conveyed the gist of the conventional British conception
of the good practitioner. Good moral character is not less necessary to
your advancement in the medical profession than skill and knowledge
. . . [you] must sympathize with others, and [be] careful not to hurt their
feelings (Brodie 1843, p. 30). As this routine lecture by a prominent but
eminently nonphilosophical physician indicates, by the mid-nineteenth
century, Gregorys medicalized Scottish moral philosophy had become
the conventional wisdom of the British medical school lecturer and of
British medicine generally.
A similar process led to the conventionalization of this ideal on the other
side of the Atlantic. Gregorys student, Benjamin Rush (17461813), signer
of the American Declaration of Independence and professor of medicine
at the University of Pennsylvania, was the most infuential physician in
eighteenth- and early nineteenth-century America. He employed Gregorys
medicalized Scottish moral philosophical discourse in his regular lectures
On the Vices and Virtues of Physicians. Foremost among physicians
vices, Rush informed his students, is an insensibility to human suffering
(Rush 1811, p. 124, compare Gregory [1772] 1998, p. 9). Not surprisingly,
physicians chief virtue is humane sympathy which Rush (1811, p. 129),
in characteristic stage-three fashion, decontextualizes from its origins in
Scottish moral philosophy, transforming it into a conspicuous virtue of
physicians among all ages and countries. No sooner do [physicians]
enter upon the duties of their profession, Rush (1811, p. 130) continues,
than they are called upon to exhibit their humanity by sympathy, with
pain and distress in persons of all ranks.
Gregorys medical ethics was also translated into French, German,
Italian, and Spanish (Gregory 1778; 1787; 1789; 1803). Although the
history of these translations has yet to be written, we have no evidence
that the ideal of the sympathetic physician was present in the medical
culture of these countries until translations of Gregorys lectures were
published in their respective languages. The concept of the sympathetic
physician, however, seems to have taken root in the medical cultures of
all the linguistic-cultural areas where translations of Gregorys lectures
were available.
CASE SKETCH: THE IDEAL OF THE UNSYMPATHETIC PHYSICIAN
It is the role of the moral revolutionary to challenge conventional
wisdom. In Weimar Germany one such revolutionary, Dr. Alfred Hoche
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(18651943), appropriated some text fragments from Nietzsche and Plato
to challenge the received medical morality by arguing that it was inap-
propriate to sympathize with, or to have reason to pity, people with
mental disabilities (Hoche [1920] 1975, p. 35). Hoches appropriation
and medicalization of fragments from Nietzsche and Plato were widely
disseminated in the German medical profession and for a while became
the received view in Germany, where it was openly taught to medical
students. Here is one students description.
The director of the Eglfnger-Haar asylum, Herman Pfannmller, an
admirer of Hoche, gave tours of the eugenic-euthanasia program to young
physicians.
Since I had studied psychology in 1934/1935 as part of my professional
training . . . I took part in a conducted tour . . . The asylum director . . .
Pfannmller, led us into a childrens ward . . . [He] explained . . . As a
National Socialist, these creatures . . . naturally only represent to me a bur-
den upon the healthy body of our nation. We dont kill (he may have used
a more circumlocutory expression . . . ) with poison, injections, etc., since
that would only give the foreign press and certain gentlemen in Switzerland
new hate propaganda material. No: as you see, our method is simpler and
even more natural. With these words, and assisted by a nurse . . . he pulled
one of the children out of the bed. As he displayed the child around like a
dead hare, he pointed out, with a knowing look and a cynical grin, This
one will last another two or three days. The image of this fat, grinning
man, with the whimpering skeleton in his feshy hand is still clear before
my eyes . . . A lady who also took part in our tour asked, with an outrage
she had diffculty suppressing, whether a quick death aided by injections
would not be more merciful. (Burleigh 1994, pp. 4546)
As the psychology student noted, Dr. Pfannmller was a follower of Hoche.
Together with the lawyer Karl Binding (18411920), Hoche had written
a small tract Die Freigabe der Vernichtung lebensunwerten Lebens (Per-
mission for the Destruction of Life Unworthy of Life) in 1920 (Binding
and Hoche [1920] 1975). Historians who have examined the intellectual
background of Pfannmller and other German physicians involved in
the eugenic-euthanasia programoften referred to as the Aktion T-4
programof euthanizing Germans with mental disability found that
Hoche had a profound infuence on these physicians. From the programs
co-director Karl Brandt (19041948) and administrators such as Viktor
Brack (19041948) to the pediatricians who selected infants for euthana-
sia, Werner Catel (18941981) and Ernst Wentzler (18911973)inven-
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tor of an incubator for premature babiesall had read Hoche or been his
students. Their discourse was studded with Hoches language, especially
lebensunwerten Lebens, the idea that certain people lived a life unworthy
of being liveda phrase from Plato that Hoche had appropriated as the
title of his book (Lifton 1986, p. 107). Most had accepted Hoches views
before joining the program (Burleigh 1994, pp. 100, 27374). Some, like
Werner Heyde (19021964), had attended Hoches lectures (Lifton 1986,
p. 117). Others report that Hoches ideas were used to recruit them into
the program (Lifton 1986, p. 104).
Binding and Hoche ([1920] 1975) had written Die Freigabe der Ver-
nichtung lebensunwerten Lebens in the immediate aftermath of World
War I, during the early years of the Weimar Republic (19191933). Living
through the last year of his own life, Binding was primarily worried about
euthanasia for terminally ill patients. Hoches exploration of the legal and
moral status of the mental incurables was stimulated by the fact that
millions of people had died in the recent war, and hard choices about
resources had been made. The fact that one of these choices involved the
mass starvation of mental patients not only went unmentioned but was
consciously denied. It is diffcult to decide whether the tract was prescrip-
tive or an uneasy and evasive ethical rationalization of what had already
taken place (Burleigh 1994, p. 15).
Both Binding and Hoche were liberals; neither was a National Socialist
(Nazi). Binding was a respected law professor, a legal positivist. Hoche
thought of himself as a humanist. Since his wife was Jewish, he was forced
into early retirement by the Nazis. He opposed National Socialist eugenic
laws, pointing out that they would have precluded the birth of . . . Goethe,
Schopenhauer, and Beethoven; and he opposed the euthanasia program
. . . even though much of its rationale derived from his own writings
(Burleigh 1994, p. 14).
Die Freigabe der Vernichtung lebensunwerten Lebens consists of 251
numbered paragraphs199 by Binding dealing with legal questions; 52 by
Hoche. The paragraphs lay out the legal and medical case for euthanasia
in the form of consensual assistance in dying (Bindings concern) and for
eugenic-euthanasiai.e., killing the mentally disabled, even though they
were incapable of consenting(Hoches concern). Since the Nazi doctors
used Hoches language, we focus on his portion of the tract. It opens with
a critique of the Hippocratic Oath, which Hoche rejects as no longer
binding (Par. 203). Hoche also critiques Christian ethics (Par. 230) in
the context of his main concern, life devoid of valuei.e., mentally
disabled, ballast persons.
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226. The question of whether we should spend all of this money on ballast
type persons of no value was not important in previous years because the
state had suffcient money. Now conditions are different. . . .
227. Opposed to our task is the modern effort to keep alive all sorts of
weaklings and to care for all those who are perhaps not mentally retarded
but are still large burdens. . . .
228. . . . The granting of death with dignity to life devoid of value to affect
the release of the burden will for a long time be met with resistance for
mostly sentimental reasons. . . .
229. In order to attain the necessary results, we must investigate . . . the
possibility and conditions for euthanasia.
233. . . . one of these days . . . we will come to the conclusion that the
elimination of the mentally dead is no crime, nor an immoral act, and no
unfeeling cruelty, but a permissible and necessary act.
234. . . . what are the qualities and effects of mental death? . . . the charac-
ter of a parasite . . . on modern society: the absence of any productivity; a
condition of helplessness; and the necessity of caring for the mentally dead
by a third person.
235. . . . The most important [characteristic] of the mentally dead person
is the lack of the possibility of . . . knowing himself, the absence of self-
consciousness. The intellectual level of the mentally dead person is that of
a very low animal and the feelings are also most elementary and similar to
those of animal life.
239. . . . People have the wrong idea about compassion [they] project their
life into the lives of other people.
240. . . . [to implement this policy] the sense of being a member of a hard
diffcult undertaking, has to become stronger than it is now.
250. . . . The [era] in which we are still living during which the support
of every [form of] existenceno matter how worthlesshas become the
highest moral norm. A new time will come when we no longer . . . carry
out this demand, which has its origins in an exaggerated ideal of humanity.
The present morality places too much value on mere continued existence
and asks too high a sacrifce. (Hoche, in Binding and Hoche [1920] 1975,
pp. 3840, emphasis added)
Hoche had borrowed a line from Plato to serve as the title of his book
and he medicalized a line from Nietzsche in characterizing people with
mental disability as parasite[s] on . . . modern society (Hoche [1920]
1975, Par. 234, p. 37). He also echoes Nietzsche in celebrating hardness
as a virtue and decrying compassion and humanismi.e., sympathy. As
Hoche no doubt intended, his contemporaries immediately recognized
these references and read him as addressing questions frst raised by
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Plato, how to deal with sick person[s] who [are] a parasite on society
(Aschheim 1992, pp. 45, 163; Kirchner 1927; Procter 1988, p. 179). What
prompted the reference to Plato was the title of the book, lebensunwerten
Lebens. The line is from an argument in Platos most famous work, the
Republic (Republic III, 405410). If a man had a sickly constitution and
intemperate habits, his life was worth nothing to himself or anyone else;
medicine was not meant for such people and they should not be treated,
though they be richer than Midas (Republic III, 408, emphasis added).
Plato goes on to say that physicians should put to death those who are
incurably corrupt in mind. . . . That will be the best thing for them as well
as for the community (Republic III, 410).
Hoche also uses a line from Nietzsche that was familiar to German
physicians. In one of his last books, Nietzsche ([1888] 1964c, 16: 88) had
written a Platonic parable for doctors.
A moral for doctors.The sick man is a parasite of society. In certain cases
it is indecent to go on living. To continue to vegetate in a cowardly depen-
dence on doctors and special treatments, once the meaning of life, the right
to life, has been lost, ought to be regarded with the greatest of contempt
by society. . . . A new responsibility should be created for the doctorthe
responsibility of ruthlessly suppressing and eliminating degenerate life, in all
cases in which the highest interests of life itself, of ascending life, demand
such a course. . . . One should die proudly when it is no longer possible to
live proudly.
Hoche gave Nietzsches words a biological twist, there is no doubt that
in trying to preserve life without dignity by all means, exaggeration has
occurred . . . We doctors know that in the interest of the whole human
organism, single, less valuable members have to be abandoned and pushed
out (Par. 231, Binding and Hoche [1920] 1975, p. 37). Hoche refers to
these less valuable members of society as Ballastexistenzeni.e., bal-
last peopleand, to reiterate, echoes Nietzsche in characterizing them
as having the character of a parasite . . . on modern society (Par. 234,
Binding and Hoche [1920] 1975, p. 37).
Hoches medicalization of texts and theory fragments from Nietzsche
and Plato was well received by many in the German medical community.
The distinguished Tbingen psychiatrist Robert Gaup, inventor of the
concept of Kriegsneurosen, or shell shock, applauded the proposal, re-
marking that he had often wondered why he was obligated to provide for
mental patients during the First World War, when people of full value
were starving to death (Burleigh 1994, p. 20). Professional medical and
BAKLR AD NCCULLOUGH APPROPRIA1IO OI NORAL PHILOSOPHY
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psychiatric societies, however, rejected Hoches recommendations at their
1921 and 1922 meetings (Burleigh 1994, p. 24). In 1925, Ewald Meltzer
(1925), director of the Katharinenhof Asylum published a detailed response
to Binding and Hoche, Das Problem der Abkzung lebensunwerten
Lebens (The Problem of the Curtailment of Life Unworthy of Life). Yet,
even though the debates of the 1920s culminated in the formal rejection
of Hoches proposals, as is evident from the title of Meltzers book, the
very process of debating and rebutting their proposals disseminated such
concepts as ballastexistenzen and lebensunwerten Lebens, facilitating
their third-stage dissemination beyond Hoches idiolect into the vocabulary
of German medicine.
One of the physicians who adopted Hoches discourse was Gerhard
Wagner, leader of the National Socialist Physicians league. In an ad-
dress to a 1935 Nazi Party Congress, Wagner decried the burden and
unexcelled injustice that the cost of care for the mentally ill placed
on normal, healthy members of the population. Deploying arguments
popularized by Hoche, Wagner appropriated Nietzschean language to de-
nounce Gleichheitslehre, the doctrine of equality that placed the value of
the sick, the dying, and the unft on par with the healthy and the strong
(Proctor 1988, p. 181). Wagners critique of Gleichheitslehre echoed a
passage from Nietzsche.
The biblical prohibition thou shalt not kill is a piece of naivet. . . . Life
itself recognizes no solidarity, no equal rights, between the healthy and
the degenerate parts of an organism: one must excise the latteror the
whole will perish.Sympathy for decadents, equal rights for the ill-consti-
tutedthat would be the profoundest immorality, that would be anti-nature
itself as morality (Aschheim 1992, p. 389; see also pp. 14142, 39193,
emphasis added).
2
National Socialist physicians would be Nietzschean, rejecting weiblich
(feminine) ideals of sympathy, hardening their hearts so that, as Hitler
promised Wagner at that conference, if war should break out . . . a
national program of euthanasia for those unworthy of life would be
initiated (Proctor 1988, p. 181; Burleigh 1994, p. 97).
Hitler kept his promise. On 18 August 1939, 14 days before the inva-
sion of Poland and the outbreak of World War II, the Committee for the
Scientifc Treatment of Severe, Genetically Determined Illness ordered
local governments to register all children with hereditary illness. Using
this registry, three physicians began selecting those children who were
lebensunwertes Leben, dispatching them to be euthanized.
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Apparently unable to accept the notion that the words of iconic philoso-
phers could have been integral to creation of the concept of lebensunwerten
Lebens and the eugenic euthanasia of thousands of Germans, apologists for
Plato and Nietzsche sometimes appeal to an applied ethics model to argue
that Hoche and the Nazi doctors had misapplied decontextualized passages
from Plato and Nietzsche. Whether or not the claim of misapplication is
valid, it rests on a fundamental misconception of the relationship between
philosophical and practical ethics, especially in contexts of moral reform
and revolution. Moral revolutionaries, like Hoche, do not turn to moral
philosophy simply to apply often-abstruse theories to practical contexts;
they turn to moral philosophy to reinterpret received conceptions and to
adapt moral philosophy to revolutionizing received morality and conven-
tional practices. Nietzsches and Platos intent in penning their words is
thus irrelevant. Hoche wanted to challenge a received medical morality
grounded in Christian ideals sanctifying all forms of human life and in the
Gregorian ideal of the humanely sympathetic physician. He knew that the
received German medical discourse with its celebration of humanity and
sympathy would never countenance the killing of the mentally disabled.
So he turned to discourse from Nietzsche and Plato to offer a medical
discourse that extolled hardness as a virtue, that derided sympathy, and
that conceptualized the mentally disabled as lebensunwertes Leben.
CONCLUSION
We have argued that doctors and others engaged in practical affairs are
not particularly prone to reading moral philosophy. However, in contexts
in which practitioners deem it necessary to defend, to reform, or to revo-
lutionize received medical morality, they often turn to moral philosophy
as a source of concepts and theory fragments adaptable to their purposes.
Language encapsulating the appropriated concepts and fragments then
becomes part of their idiolect: to the extent that their views infuence their
students and their peers, that language subsequently enters and shapes the
discourse of their feldperhaps even the received culture generally.
If our analysis of appropriation as the intellectual driver in the relation-
ship between moral philosophy and medical ethics is correct, the authors
and editors of bioethics textbooks need to cease putting snippets from
Aristotle, Kant, and Mill in the opening chapters of their books. Although
their intent, no doubt, is to valorize bioethics, the effect of these invocations
is to marginalize the role of bioethicists and to eclipse the actual histori-
cal impact of moral philosophy on practical ethics. We need to focus our
BAKLR AD NCCULLOUGH APPROPRIA1IO OI NORAL PHILOSOPHY
| i, ]
attention on the real achievements of practical ethicists like Gregory and
such contemporary bioethical innovators as Tom Beauchamp and James
Childress. Analyzing their seminal works in the context of their role as
moral innovators offers students the opportunity to study the process
of conceptual adaptation and innovation that is the dominant source of
moral philosophys infuence on practical ethics and moral practice (Baker
2002). Taking an appropriation model seriously also will put substantive
historical teeth into the ideal of an interplay between theory and practice
envisioned by pragmatic bioethicists (McGee 2003) and wide refective
equilibrium theorists (Buchanan et al. 2000, Appendix II).
Finally, analyzing the historical process of appropriation and innova-
tion in practical ethics opens the door to studying the dynamics, the suc-
cesses, and the failures of moral reform and revolution. For, as Hoches
self-admitted failure underlines, even successful moral revolutionaries may
not make the world a better place. Bioethicists and their students need
to analyze and learn from the actual history of moral appropriation and
innovation because the forces driving change in biology and medicine,
the forces that created the initial need for the bioethics revolution of the
1970s, have not lost momentum.
We face a future of continued challenge. We will need ever-greater con-
ceptual creativity to meet these challenges. We serve the next generation
of bioethicists best, not by valorizing our feld by associating it with iconic
philosophers, but by teaching our students to appreciate the successes and
failures of our real precursors, Gregory, Percival, and, sadly, Hoche.
NOTES
1. In a lecture delivered in 1769, the Edinburgh-educated American physician
Samuel Bard (17421821) wrote it is . . . your Duty . . . to avoid wound-
ing . . . Sensibility. Let your Carriage be humane and attentive (Bard 1769,
pp. 2021). Although less philosophical than Gregory, Bard, who had been
exposed to Scottish moral philosophy, seems to embrace the ideal of the
sympathetic physician.
2. Nietzsches pro-Nazi sister edited this work; however, similar passages abound, in
works she did not edite.g., The Geneaology of Morals (Nietzsche [1887] 1964b,
pp. 120125) and Zarathustra (Nietzsche [1883/1885] 1964a, pp. 18386).
REFERENCES
AMA. American Medical Association. [1847, 1994] 1999. Code of Ethics. In
The American Medical Ethics Revolution, edited by Robert Baker, Arthur
KLLDY IS1I1U1L OI L1HICS ]OURAL NARCH zoo;
| zo ]
Caplan, Linda Emanuel, and Stephen Latham, 2.20, pp. 32434. Baltimore,
MD: Johns Hopkins University Press.
. 2007. Code of Ethics E. 2.20: Withholding or Withdrawing Life Sustain-
ing Treatment. Available at http://www.ama-assn.org/ama/pub/category/8457.
html. Accessed 28 January 2007.
Andre, Judith. 2002. Bioethics as Practice. Chapel Hill: University of North
Carolina Press.
Aschheim, Steven E. 1992. The Nietzsche Legacy in Germany, 18901990.
Berkeley: University of California Press.
Baker, Robert. 2002. Bioethics and History. Journal of Medicine and Philosophy
27: 44976.
, and McCullough, Laurence. 2007. The Discourses of Philosophical Medi-
cal Ethics. In A History of Medical Ethics, ed. Robert Baker and Laurence
McCullough. New York: Cambridge University Press, in press.
Bard, Samuel. 1769. A Discourse Upon the Duties of a Physician, With Some
Sentiments, on the Usefulness and Necessity of a Public Hospital, Delivered
Before the President and the Governors of Kings College, at the Commence-
ment, held on the 16th of May, 1769. As Advice to those Gentlemen who
then received the First Medical Degrees conferred by that University. New
York: A & J Robertson.
Beauchamp, Tom L., and Childress, James F. 1979. Principles of Biomedical
Ethics. New York: Oxford University Press.
Binding, Karl, and Alfred E. Hoche. 1920. Die Freigabe der Vernichtung lebensun-
werten Lebens: Ihr Mass und ihre Form. Leipzig: Verlag von Felix Meiner.
. [1920] 1975. The Release and Destruction of Life Devoid of Value: Its
Measure, trans. Robert Sassone. Santa Ana, CA: Robert Sassone.
Brodie, Sir Benjamin C. 1843. Introductory Discourse on the Duty and Conduct
of Medical Students and Practitioners: Addressed to the Students of the Medi-
cal School of St. Georges Hospital, October 2, 1843. London: Longman,
Brown, Green, and Longmans.
Buchanan, Allen; Brock, Dan; Daniels, Norman; and Wikler, Daniel. 2000. From
Chance to Choice. Cambridge, UK: Cambridge University Press.
Burleigh, Michael. 1994. Death and Deliverance: Euthanasia in Germany,
19001945. Cambridge and New York: Cambridge University Press.
Cohen, I. Bernard. 1985. Revolution in Science. Cambridge, MA: The Belknap
Press of Harvard University Press.
Evans, John H. 2002. Playing God? Chicago: University of Chicago Press.
Fox, Daniel M. 1979. The Segregation of Medical Ethics. Journal of Medicine
and Philosophy. 4: 8197.
BAKLR AD NCCULLOUGH APPROPRIA1IO OI NORAL PHILOSOPHY
| zi ]
Gadamer, Hans-Georg. 1996. The Enigma of Health. Stanford, CA: Stanford
University Press.
Gisborne, Thomas. 1789. The Principles of Moral Philosophy Investigated and
Briefy Applied to the Constitution of Civil Society. London: B. & J. White.
. 1794. An Enquiry into the Duties of Men in the Higher and Middle
Classes of Society in Great Britain Resulting from their Respective Stations,
Professions and Employment. London: B. & J. White.
Gregory, John. 1759. An Inquiry into Those Faculties which Distinguish Man from
the Rest of Animal Creation. Aberdeen University Library, MS 3107/1/4.
. 1765. A Comparative View of the State and Faculties of Man with Those
of the Animal World. London: J. Dodsley.
. [1770] 1998. Observations on the Duties and Offces of a Physician, and
on the Method of Prosecuting Enquiries in Philosophy. In John Gregorys
Writings on Medical Ethics and Philosophy of Medicine, ed. Laurence B.
McCullough, pp. 93159. Dordrecht: Kluwer Academic Publishers.
. [1772] 1998. Lectures on the Duties and Qualifcations of a Physician. In
John Gregorys Writings on Medical Ethics and Philosophy of Medicine, ed. Lau-
rence B. McCullough, pp. 161245. Dordrecht: Kluwer Academic Publishers.
. 1778. Vorlesungen ber die Pfichten und Eigenschaften eines Artzes:
Aus dem Englischen nach der neuen und verbesserten Ausgabe, translator
unknown. Leipzig: Caspar Fritsch.
. 1787. Discours sur les devoirs, les qualities et les connaissances du mdi-
cin, avec un cour dtudes, trans. B. Verlac. Paris: Crapart & Briands.
. 1789. Lexioni Sopra I Doveri e la Qualita di un Medico, trans. F. F.
Padovano. Florence: Gaetano Cambiagi.
. 1803. Discurso sobre los deberes, qualidades y conocimientos del medico,
con el mtodo de sus estudios. Madrid: Imprenta Real.
Haakonssen, Lisbeth. 1997. Medicine and Morals in the Enlightenment. Amster-
dam: Editions Rodopi.
Hume, David. [1739] 2000. A Treatise of Human Nature, ed. David Fate Norton
and Mary J. Norton. Oxford: Oxford University Press.
Kirchner, E. 1927. Anfnge rassenhygienischen Denkens in Morus Utopia und
Campanellas Sonnenstadt. Archiv fr Rassen- und Gesellschaftsbologie 21.
Lifton, Robert J. 1986. The Nazi Doctors: Medical Killing and the Psychology
of Genocide. New York: Basic Books.
McCullough, Laurence B. 1998. John Gregory and the Invention of Professional
Medical Ethics and the Profession of Medicine. Dordrecht: Kluwer Academic
Publishers.
McGee, Glenn. 2003. Pragmatic Bioethics. Cambridge, MA: MIT Press.
KLLDY IS1I1U1L OI L1HICS ]OURAL NARCH zoo;
| zz ]
Meltzer, Ewald. 1925. Das Problem der Abkzung lebensunwerten Lebens.
Halle: Marhold.
More, Ellen. 1994. Empathy Enters the Profession of Medicine. In The Em-
pathic Practitioner, ed. Ellen More and Mary Milligan, pp. 1939. New
Brunswick, NJ: Rutgers University Press.
National Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research. 1979. The Belmont Report. Washington, DC: U.S.
Government Printing Offce. Available at http://ohsr.od.nih.gov/guidelines/
belmont.html. Accessed 28 January 2007.
Nietzsche, Friedrich. [1883, 1885] 1964a. Thus Spake Zarathustra. In The Com-
plete Works of Friedrich Nietzsche: First Complete and Authorised English
Translation, ed. Oscar Levy, trans. Anthony M. Ludovici. New York: Russell
& Russell.
. [1887] 1964b. The Geneaology of Morals. In The Complete Works of
Friedrich Nietzsche: First Complete and Authorised English Translation, ed.
Oscar Levy, trans. Anthony M. Ludovici. New York: Russell & Russell.
. [1888] 1964c. The Twighlight of the Idols: Or, How to Philosophise with
the Hammer. In The Complete Works of Friedrich Nietzsche: First Complete
and Authorised English Translation, ed. Oscar Levy, trans. Anthony M.
Ludovici. New York: Russell & Russell.
Percival, Thomas. 1803. Medical Ethics. London: J. Johnson & R. Bickerstaff.
Proctor, Robert N. 1988. Racial Hygiene: Medicine Under the Nazis. Cambridge,
MA: Harvard University Press.
Ramsey, Paul. 1970. The Patient as Person. New Haven, CT: Yale University
Press.
Rush, Benjamin. 1811. Medical Inquiries and Observations. Philadelphia, PA:
J. Conrad & Co.
Slote, Michael. 1995. The Task of Ethics. In Encyclopedia of Bioethics, revised
edition, ed. Warren T. Reich, Vol. 2, pp. 72027. New York: Macmillan.
. 2004. The Task of Ethics. In Encyclopedia of Bioethics, 3d ed., ed. Ste-
phen Post, Vol. 2, pp. 795802. New York: Thomson-Gale.
Spiro, Howard. 1993. What is Empathy and Can It be Taught? In Empathy and
the Practice of Medicine, ed. Howard M. Spiro, Mary G. Mccrea Curnen,
Enid Peschel, and Deborah St. James, pp. 714. New Haven, CT: Yale Uni-
versity Press.
Veatch, Robert M. 2005. Disrupted Dialogue. New York: Oxford University
Press.
Contributors
robert baker, ph.d., is Director, Center for Bioethics & Clinical Leadership, Union
Graduate College, and William D. Williams Professor of Philosophy, Union College,
Schenectady, NY.
tom l. beauchamp, ph.d., is Senior Research Scholar, Kennedy Institute of Ethics,
and Professor of Philosophy, Georgetown University, Washington, DC.
daniel m. fox, ph.d., is President of the Milbank Memorial Fund, New York,
NY.
albert r. jonsen, ph.d., is Emeritus Professor of Ethics in Medicine, University
of Washington, Seattle, and Co-Director, Program in Medicine and Human Values,
California Pacific Medical Center, San Francisco, CA.
laurence mccullough, ph.d., is Professor of Medicine and Medical Ethics,
Center for Medical Ethics and Health Policy, and a Faculty Associate, Huffington
Center on Aging, Baylor College of Medicine, Houston, TX.
ulf schmidt, d.phil., is a Senior Lecturer in Modern History in the School of
History at the University of Kent, Canterbury, and a Fellow of the Royal Historical
Society.
jeremy sugarman, m.d., m.p.h., m.a., is Harvey M. Meyerhoff Professor of
Bioethics and Medicine, Berman Institute of Bioethics, Johns Hopkins University,
Baltimore, MD.
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