Medicine, Health Care and Philosophy 6: 75–77, 2003.

Review article

A life in bioethics

Gerd RichterUniversity of Marburg, Zentrum Innere Medizin, Marburg, Germany

Miller, F.G. (ed.): 2000, Frontiers in Bioethics. Essaysdedicated to John C. Fletcher. Hagerstown: UniversityPublishing Group. 216 pages. ISBN: 1-55572-075-7.Price: $ 19.95.

This book serves as a “Festschrift” to John C.Fletcher, Professor emeritus of Biomedical Ethics atthe University of Virginia and one of the pioneers inbioethics. It contains nine essays by colleagues andformer students of John C. Fletcher, that display thefruits of research, reflection, and practical engagementin the field of bioethics as the results of their ownwork and as steps in John C. Fletcher’s career asa pioneering bioethicist alike. The book highlightsissues like research with human subjects, genetics andethics, reproductive medicine and ethical quandaries,clinical ethics in theory and practice, physician-assisted suicide, organisational ethics, and ethicalproblems in managed care. I will review the essays asthey match the career of Dr. Fletcher, which has beenwell described in the introductory essay by the editorFranklin G. Miller.

Related to Fletcher’s earliest research in bioethics(his PhD dissertation “A Study of the Ethics of MedicalResearch” at the Clinical Center of the National Insti-tutes of Health (NIH) during the period from 1966–1968), Jonathan Moreno, who succeeded Dr. Fletcheras Director of the Center for Biomedical Ethics atthe University of Virginia, sheds some light on theinfluence of the Nuremberg Code upon certain aspectsof the evolution of research standards in the UnitedStates (chapter 2). Based on an historical perspectiveof various documents and his own work on the staff ofthe President’s Advisory Committee on Human Radia-tion Experiments, Moreno challenges the prevailingview that the Code had no influence on the post-war United States. Interestingly, he argues that theCode was influential to non-physician governmentadministrators and attorneys in the national secur-ity establishment, although the Code’s influence didat first not reach the medical profession or researchcommunity.

The first chapter, “Society and the Not-So-NewGenetics: What Are We Afraid Of? Some FuturePredictions from a Social Scientist” by Dorothy Wertzexemplifies the value of empirical research in bioe-thics. The essay describes findings from two wellregarded and cited international surveys of geneticiststhat the author has conducted in collaboration with Dr.Fletcher.

In chapter 5 Paul Lombardo writes on “Medicine,Eugenics, and the Supreme Court: From CoerciveSterilization to Reproductive Freedom” and pointsto the almost forgotten American history of eugenicthoughts with three important legal cases. He high-lights and explains how current language of repro-ductive rights, including constitutional protection forprocreation and limits to reproductive freedom, can betraced to the three eugenic cases.

Besides genetics Dr. Fletcher early on was inter-ested in the developing field of assisted reproductivetechnologies and its surrounding problems. In hisscholarship and organisational activities, Dr. Fletcherdisplayed the rare quality of graciously acceptingcriticism and learning from his mistakes. An articleentitled “On Learning from Mistakes” reflects Dr.Fletcher’s position on controversial questions regard-ing the ethics of selective termination (J Clin Ethics,1995, 6, pp. 264–270). Assisted reproductive techno-logies have pushed prospective parents, professionals,and society into unsettled territory. Mary Rorty andJoAnne Pinkerton (chapter 6) discuss fetal reductionin the context of artificial reproductive technologies.Drawing on a case of a woman who has naturallyconceived twins but wishes to give birth to only onechild, the authors deliver a solid and thoroughly ethicalcase analysis with outstanding clarity of its medical,technological, and ethical aspects. This paper is also avery readable introduction into the problem of selec-tive reduction caused by the new assisted reproductiontechniques and shows clearly that the ethical import ofselective reduction varies with differing clinical situa-tions, and raises difficult issues not only for Americansociety.

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In 1977 Dr. Fletcher became the fist bioethicist inresidence at the Clinical Center of NIH, which canalso be viewed as the birth of clinical ethics and hecontinued to develop a clinical ethics programme andconsultation service at the University of Virginia. Inhis words ethics is a practical discipline that deals withreal-world problems and practices in modern clinicalmedicine. Proceeding by trial and error, Dr. Fletcherpioneered in creating and understanding the role of theethics consultant as a facilitator of moral discourse andproblem solving, aimed at reaching agreement on aplan of action among all those concerned with a casethat poses considerable moral conflict or perplexity. Ifethics consultation is a professional service, then ethicsconsultants need to satisfy standards of training andcompetence. Defining and promoting such standardsis a goal that Dr. Fletcher has assiduously pursued.Moral problems in clinical practice arise in the contextof particular cases of patient care. Clinicians facedwith morally problematic situations need to know howto assess the morally relevant details of the case andapply general moral considerations, rules, principles,standards, and virtues, in order to arrive at a satis-factory resolution. In chapter 4, Franklin G. Miller,Joseph J. Fins and Matthew D. Bacchetta, colleaguesand co-workers of Dr. Fletcher, lay out a method ofmoral problem solving that they call clinical pragma-tism, which is inspired by the thought of the Americanphilosopher John Dewey. They developed their formu-lation of clinical pragmatism in the spirit of Dewey’spragmatic philosophy. The method is clinical becauseit is focused on the circumstances of particular casesof patient care and attentive to the norms and virtuesof clinical practice. It is pragmatic because it aimsto guide the development, implementation, and eval-uation of ethically appropriate and effective plans ofaction by means of a collaborative process of prob-lem solving involving all those concerned with thecase. The method of clinical pragmatism, in contrastto principlism or casuistry, deploys principles andother moral considerations as working hypotheses,to provide orientation and guidance in moral prob-lem solving. It aims to arrive at carefully considered,principled judgements about what to do in morallyproblematic cases, however, clinical pragmatism isattentive to the details of the clinical situation andin the context of a collaborative process of inquiry,negotiation, and decision making.

One of the most controversial and heavilydiscussed moral problems in American society is theissue of physician-assisted suicide. Probably no otherdilemma of bioethics has received and is still recei-ving more public attention than this. The debateover this issue can be characterised by its partisanrhetoric and bald assertions. John Arras undertakes

in his essay (chapter 3) a nuanced evaluation ofcompeting considerations, especially potential socialconsequences, that should be taken into account byadvocates of legalising assisted suicide.

As managed care came up in the realm of UShealthcare in the beginning of 1990, Dr. Fletcher earlyon started to think about the possible meaning ofthat with regard to the ethics of patient care. In theirinsightful essay on organisational ethics (chapter 8),Edward Spencer and Ann Mill mark the point whereclinical, business, and professional ethics intersect.Organisation ethics consists of a process to addressethical issues associated with business, financial, andmanagement areas of healthcare organisations, as wellas with professional, educational, and contractual rela-tionships affecting the operation of the healthcareorganisation. As they make clear, organisational ethicsconcerns the ethical climate of healthcare institutions,mediating between social health policy and patientcare. That is of particular interest in the situation ofmanaged care and managed-care organisations.

In chapter 7 Jim Childress, best known as theco-developer of the leading theoretical perspective of“principlism” and a colleague of Dr. Fletcher at theUniversity of Virginia, illuminates the role of meta-phor in shaping moral perceptions of healthcare bythe situation of managed care in the United States.He explains and interprets the US healthcare systemin the time of managed care metaphorically by meansof the previously dominant but still persistent meta-phor of “medicine as warfare against disease” and thenew contender “medicine as business or commerce”.He goes on to explain that both the military and themarket metaphor appear in the ordinary language,concept, and practices. And both illuminate and distortwhat is and what ought to be. But he reaches theresult that both military and economic metaphors illu-minate certain aspects of healthcare, but may not beadequate, even together, to guide and direct health-care. Whether any particular metaphor is able to guidepolicies, practices, an action will depend at least inpart on the values it highlights and hides, such asjustice, fairness, equity; care, compassion, solidarity;liberty; and efficiency. Also including other meta-phors like the ecological or nursing metaphor withtheir values like integrity, balance, natural, quality,diversity, conservation, community, caring and curing,an adequate metaphor must somehow fit the real world– at least its emergent possibilities. Childress mentionsthat managed care has profoundly altered the practiceof medicine in the United States and a metaphor thatwould be suitable for this situation must also take intoconsideration the conflicts of obligations, conflicts ofinterest, threats to public and patient trust, and ethicalconflicts that arose within managed care.

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The final essay (chapter 9), written by Mary FaithMarshall, who became a bioethicist under the influenceand mentoring of Dr. Fletcher, demonstrates JohnFletcher’s teaching that facing ethical controversiescalls for courage and self-examination. This kind ofattitude is demonstrated by the author’s dealing andstruggle with the Interagency Policy on Managementof Substance Abuse During Pregnancy of her ownUniversity/Medical School. The policy, presentedby the university’s general counsel, resulted in thearrest of more than 40 patients who used illegal drugswhile pregnant and who failed to undergo treatmentfor substance abuse. The policy conditioned freedomfrom arrest on compliance with mandatory prenataland substance abuse treatment. The programme wasa joint venture between the obstetrics department ofthe Medical School, the local prosecutor, and the localpolice department. After a lawsuit was filed in thefederal district court on behalf of some of these formerpatients who had been arrested under the policy, the

author of this essay describes her personal struggle andalso her scientific approach to this particular ethicalproblem. To handle this issue personally and in ascientific way demands a lot of the important charactertraits identified in the “Core Competencies for HealthCare Ethics Consultation” of the American Society forBioethics and Humanities, which are 1.) tolerance,patience, and compassion; 2.) honesty, forthrightness,and self-knowledge; 3.) courage; 4.) prudence andhumility; and 5.) integrity. This essay should be ofspecial interest for all European ethicists, who are nowbeginning to explore the field of clinical ethics andethics consultation.

This book is well edited and brings to our know-ledge a wide range of issues in clinical ethics that iscovered by the life of one of the pioneers in bioethics.The nine essays are excellently written and it shouldbe a pleasure for everybody to read them. The book isstrongly recommended to everybody who is interestedin the arising field of European clinical ethics.