From Public Health to Medical Ethics, 1960s-1980s
Nature, Society, and the Individual
Francis Zimmermann
revised March 5, 2008 (in the aftermath of our meetings)
Other contributors to this Summer School have emphasized the centrality of the concepts of Public Health and the political economy of health in the interdisciplinary field that we are attempting to construct. The impact of contemporary ethics on all recent approaches to health issues, however, should not be underestimated. Two intertwined dialectics have been at play since the 1960s, the first one going on between the Public space of policies and the Private life of individuals, and the second one between the aesthetic or sensual values of Health and the rules of Ethics. From this particular angle and my own work as a South Asianist working on Ayurvedic medicine, I would like to offer some retrospective views on the 1960s-1980s, when medical ethics developed simultaneously with the new vogue for alternative medicine.
I have been careful not to decontextualize the recent historical facts I wished to compare, and this presentation focusses on North America, the USA and, for most of the cultural events alluded to, the West Coast of the United States, thus keeping the narrative within one and the same local moral world which somehow constitutes the birthland of a number of postmodern conceptions and practices.
I shall plead guilty for comparing events that are not of the same “order of magnitude” although they occurred in the very same North-American historical, cultural and political “world” from the 1960s through the 1980s:
1 / turning points in the history of medical ethics, environmental ethics and bioethics;
2 / landmarks in the history of American Counter-Culture and the advent of Deep Ecology;
3 / breakthroughs in biomedical technologies;
4 / revivals of Eastern cosmologies and teleologies embedded in Asian medical systems;
5 / new departures in the layman’s medical experience and practices.
I am well aware of my entering a highly specialized field; all the more so when I shift from medical ethics to bioethics. In such an attempt to locate, to assess and to delineate a particular historical period and a specific pattern in the relationships between Nature, Society and the Individual (as concepts and values), we need to apply a multiplicity of criteria that far exceed my capabilities. The narrow angle from which I approach historical facts, is that of a South Asianist. South Asian philosophy and anthropology — this is my surmise — have been playing a significant role in the history I would like to recall.
The rediscovery of Ayurveda in the West began in the 1970s when Charles Leslie launched the revival of academic research on Asian medicine. This emergence of a new interdisciplinary domain, regrouping historians, philologists, philosophers and anthropologists, that eventually ended up in the expansion of Ayurveda in the West, must be placed back in the context of the various countercultural trends that developed in North America in the 1950s.
The dominant paradigm, in all academic approaches to Nature, until the turning point of the early 1970s was still the Frankfurt School of ‘critical theory’. Horkheimer and Adorno wanted to replace the narrow positivistic model of rationality with the so-called ‘Romantic’ values of the aesthetic, moral, sensual and expressive aspects of human nature. The oppression of what they called ‘outer nature’ (i.e., the natural environment) through science and technology, they argued, was bought at a very high price: the project of domination required the suppression of our ‘inner nature’. But very soon this problematics blended into the emergent philosophical movement of ‘Deep Ecology’. The impact of Ayurveda on contemporary ethics and environmentalism dates back from the time of this encounter between Critical Theory and Deep Ecology, that brought to the fore the Sanskrit concepts of maitrî or karunâ, “compassion [for all living beings],” the idea of a bond of nature, and the philosophical assumption of interactions between humans and animals. Medical ethics and environmental ethics were both influenced at about the same time by ideas coming from the Orient.
In the literature on environmental ethics the distinction between instrumental value and intrinsic value (i.e., non-instrumental value) has been of considerable importance. The former is the value of things as means to further some other ends, whereas the latter is the value of things as ends in themselves regardless of whether they are also useful as means to other ends. For example, a medicinal plant has instrumental value since it provides the ingredients for some medicine. But if the plant also has some value in itself independently of its utilitarian prospects for furthering human health, then the plant also has an intrinsic value — a moral “standing” if not even a personality — which generates a moral duty on the part of moral agents to protect it or at least refrain from damaging it. This is an elementary formulation of the principle of nonmalevolence which prevails in contemporary Medical Ethics.
Therefore, parallel to the centrality of the concept of Public Health, I would like to set the concept of the Person back into the context of medical issues. A rapprochement I would like to make, in the mid-1970s, is between, on the one hand, the advent of a “Politics of Personhood” as Dorothy Nelkin (1983) phrased it (see bibliography, below), and, on the other hand, the multidisciplinary conferences (hereafter published) on Karma and the Hindu Person initiated by anthropologists (one of the culminations of the American school of symbolic anthropology).
Preliminary non-Asianist bibliography
jonsen_birth_bioethics.pdf — Albert R. Jonsen; Shana Alexander; Judith P. Swazey; Warren T. Reich; Robert M. Veatch; Daniel Callahan; Tom L. Beauchamp; Stanley Hauerwas; K. Danner Clouser; David J. Rothman; Daniel M. Fox; Stanley J. Reiser; Arthur L. Caplan, Special Supplement: The Birth of Bioethics, The Hastings Center Report, Vol. 23, No. 6. (Nov. - Dec., 1993), pp. S1-S16.
petersen_governmentality — Alan Petersen, Governmentality, Critical Scholarship, and the Medical Humanities, Journal of Medical Humanities, Volume 24, Nos. 3-4, December 2003: Bioethics and the Later Foucault, pp. 187-201.
petersen_medical_humanities — Alan Petersen, Alan Bleakley, Rainer Brömer et Rob Marshall, The Medical Humanities Today: Humane Health Care or Tool of Governance?, Journal of Medical Humanities, Volume 29, No. 1, March 2008, pp. 1-4.
This presentation will refer specifically to:
The Milbank Memorial Fund Quarterly. Health and Society, Vol. 61, No. 1, Special Issue: The Problem of Personhood: Biomedical, Social, Legal, and Policy Views, Winter, 1983.
maklin_personhood_bioethics.pdf — Ruth Macklin, Personhood in the Bioethics Literature, The Milbank Memorial Fund Quarterly. Health and Society, Vol. 61, No. 1, 1983, pp. 35-57.
nelkin_politics_personhood.pdf — Dorothy Nelkin, The Politics of Personhood, The Milbank Memorial Fund Quarterly. Health and Society, Vol. 61, No. 1, 1983, pp. 101-112.
fox_willis_personhood.pdf — Renée C. Fox; David P. Willis, Personhood, Medicine, and American Society, The Milbank Memorial Fund Quarterly. Health and Society, Vol. 61, No. 1, 1983, pp. 127-147.
A Tentative Chronology
1954
Joseph Francis Fletcher, Morals and Medicine. The Moral Problems of: The Patient's Right to Know the Truth, Contraception, Artificial Insemination, Sterilization, Euthanasia, Princeton, 1954.1957
John Burdon Sanderson Haldane (1892-1964), takes offence at the Suez expedition (Oct 31-Nov 6, 1956) and resigns from his University of London professorship to emigrate to India. Indigenization of knowledge (Genetics) in a postcolonial context.1960
John F. Kennedy elected President of the US.
The FDA (Food and Drug Administration) sanctions birth control pill commercialization.1962
Alan Watts, The Joyful Cosmology. Classic of Counter-Culture. Discovers Buddhism.
Rachel Carson, Silent Spring. The Bible of militant ecology.1964
Clean Air Act (provisions against atmospheric pollution in the US).
Civil Rights Act (bans segregation). Emergence of a new culture: the systematic questioning of legal authorities, and the systematic promotion of individual rights.
World Medical Association Declaration of Helsinki concerning medical experiments on humans. The idea of Ethics Committees is born.1965
Beginnings of massive LSD production in Los Angeles. LSD will be banned in California on Oct 6, 1966.1966
Cigarette US manufacturers are compelled by law to print a health warning on all paquets.1967
First heart transplantation (Christian Barnard, South Africa).
Alvan R. Feinstein, Clinical Judgement, Huntington, NY: Krieger, 1967. First phrasing of the disease—illness dichotomy.
June 16, first Pop Festival in Monterey (California) attracting flower children from all countries of the world, followed by the Summer of Love (culmination of the hippie movement), and in August the Festival of Om (Hindu reference).1969
540,000 American troups in Vietnam. Students protest at Harvard, Berkeley.
July 24, Armstrong and Aldrin walk on the moon.
August 15-17, Woodstock Festival (400,000 hippies).
National Environmental Policy Act.
First turning point in the history of American “Bioethics” (the word dates back to 1971): Experiments become the host issue; first Evaluation Committees.1970
April 22 is declared Earth Day by ecology activists.1972
Horacio Fabrega Jr & Peter Manning, “Disease, illness, and deviant careers,” in R.A. Scott & J.D. Douglas, eds., Theoretical Perspectives on Deviance, New York: Basic Books, 1972. First occurrence of the disease—illness dichotomy in Anthropology, displacing the received wisdom of ‘nature—culture’ and ‘physical—mental’ dichotomies.
Mineral King Valley Case. Christopher D. Stone, “Should Trees Have Standing? Toward Legal Rights for Natural Objects,” Southern California Law Review, Vol. 45 (1972), p. 450.1973
March 27, in Garhwal (North India), birth of the Chipko andolan.
Arne Naess [Philosopher, Oslo], “The shallow and the deep, long-range ecology movements. A summary,” Inquiry [Norway]16 (1973): 95-100. Birth of Deep Ecology.
Arthur M. Kleinman, “Medicine’s Symbolic Reality. On a Central Problem in the Philosophy of Medicine,” in the very same issue of Inquiry 16: 206-213. Birth of American critical anthropology of medicine: the clinical reality is culturally constructed.1974
Hans Jonas (Chicago), Philosophical Essays. From Ancient Creed to Technological Man, Englewood Cliffs, NJ: Prentice-Hall, 1974. The teleological or heteronomic dimension of Bioethics.
William Fox, “Deep ecology: a new philosophy for our time?,” The Ecologist 14 (1974): 194-200.1975
Asilomar Conference on Recombinant DNA (genetic manipulations).1976
Karen Quinlan Case. New turning point in American medical ethics: the deontological dimension and the patient’s autonomy come to the fore.
Conference organized by Charles Leslie, Theoretical Foundations for the Comparative Study of Medical Systems, Washington DC (re. Social Science & Medicine, vol. 12 no. 2B, April 1978).
Preliminary meeting in Lake Wilderness (Seattle), Oct 22-23, followed by two conferences on Karma in 1977 et 1978, later published as Wendy Doniger O'Flaherty, ed., Karma and Rebirth in Classical Indian Traditions, Berkeley, 1980, and Charles F. Keyes & E. Valentine Daniel, eds., Karma. An Anthropological Inquiry, Berkeley, 1983.
Clifford Geertz, “'From the native's point of view': On the nature of anthropological understanding,” in Henry A. Selby & Keith M. Basso, eds., Meaning in Anthropology, Albuquerque, 1976.
Michel Foucault, La Volonté de savoir. From 1976 onwards through his death in 1984, Foucault shifted his interests from Biopolitique to Subjectivité.1978
Birth of the first baby conceived by in vitro fertilisation, Louise Brown, UK.1979
Dec 5, Lunar (Registry) United Nations Moon Treaty. Article No. 11: Moon and its natural ressources are humanity’s common heritage (“le patrimoine commun de l'humanité”).1980
Ronald Reagan becomes US President.
Publication of DSM III (Diagnostic and Statistical Manual of Mental Disorders). Occultation of the physician’s subjectivity.1983
Margaret Trawick Egnor, “Death and nurturance in Indian systems of healing,” Social Science & Medicine, vol. 17 no. 14, 1983, part of a symposium, New Research on Traditional Medicine in South Asia, organized and edited by Charles Leslie.1984
E. Valentine Daniel, Fluid Signs. Being a Person the Tamil Way, Berkeley, 1984.1984
E. Valentine Daniel & Judy F. Pugh, eds., South Asian Systems of Healing = Volume 18 of Contributions to Asian Studies [Leiden, Brill], 1984. The very same issue contains also: Robert A. Hahn, “Rethinking 'Illness' and 'Disease',” later repr. R.A. Hahn, Sickness and Healing. An Anthropological Perspective, New Haven: Yale, 1995, and: Margaret Trawick Egnor, “The changed mother, or what the smallpox goddess did when there was no more smallpox.”1985
Conference organized by Charles Leslie, Permanence and Change in Asian Medical Systems, Washington DC, Décembre 1985 (re. Ch. Leslie & Allan Young, Paths to Asian Medical Knowledge, Berkeley, 1992).1986
Buntland Report on sustainable development.1992
Earth Summit, Rio de Janeiro. The two concepts of sustainable development and precautionary principle become international mottos.