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Guest Post by Robert Rivers (PhD student, Interdisciplinary Graduate Studies Program, University of British Columbia)

Who benefits presenting scarcity as a natural state in health care? Who killed the Hippocratic Oath? Why are doctors portrayed as paternalistic? Why has patient care become a secondary concern to budgetary constraints? The answer is the bioethicists, according to Tom Koch in his newest book Thieves of Virtue: When Bioethics Stole Medicine. The book piles scorn on the “practical philosophers” who arrived on the medical scene during the 1960s and, according to the author, have since become the neo-liberal agents who provide moral justification for putting state and commercial economic interests before patient care.

Koch claims that “[t]he idea of scarcity became the defining idea that led bioethics away from the old Hippocratic ethic of community and care down the path what it has become today” (p 54). Bioethicists, having engineered the coup against the old ethic, then took to attacking those who upheld it, declaring that “[t]he mythology of bioethics asserts that in the 1980s the nascent ethic was advanced as the champion of patient autonomy and choice. It was this that in part distinguished bioethics from the old Hippocratic ethic that was, the new philosopher-ethicists asserted, unacceptably paternalistic” (p 69).

Koch presents examples of what happens when the patient-first principles of the old Hippocratic Oath are ignored, such as the classic Buck v. Bell forced sterilization based on intelligence, non-intervention against syphilis among African Americans infected in Georgia from 1932 to 1972, the active injection of hepatitis in orphans attending the Willow Brook State School by the Armed Forces Epidemiology Board, and the Nazi atrocities.

In chapter four, “Lifeboat Ethics: Scarcity as an Unnatural State”, the reader is introduced to the historical sinking of the William Brown on the 19th of April 1841 as a powerful metaphor that underlies the author’s accusation that we allow scarcity to be manufactured through ignoring, or being told to ignore, obvious structural problems inherent in our current health care system. This historical tragedy was avoidable as economic interest overtook passenger safety. The ship went down with only one lifeboat and, as the night progressed, the first mate jettisoned a dozen passengers to their death into the icy arctic waters fearing scarcity of resources – but the boat was rescued soon after. Economic gain was at the heart of the tragedy as the captain, fearing loss of time bonus, was following shortest route from London to New York, which passed through water known to be filled with icebergs, under full sail and at night. This same tragedy would play out under similar conditions many years later with the sinking of the Titanic following the same route. Government failed to enforce having enough lifeboats on all ships due the supposed economic hardship touted by lobbyist ship owners. For Koch this is analogous to the present state of health care.

In general the readability makes the book great for those who have an interest in exploring new ideas or who have a distrust of bioethicists. But, as interesting and provocative the book promises to be, there are some criticisms. The argument is repetitive as the author attempts to point all evidence back at the bioethicist. Koch does not take the opportunity to engage in a deeper discussion of “Principlism” and its appearance during the introduction of neo-liberalistic policies to health care. In this manner Koch could have balanced his position between bioethicists’ emergence within a larger macro level political and ideological shift and his sole focus on damning of these enterprising philosophers. Finally, the author’s unflinching support for the Hippocratic Oath at times shows him perpetrating the same faults that he detects in the bioethicists, mainly the unsubstantiated claims that their approach to decision making is more moral than the old ethic.

That said, I recommend this book to those who wish to begin considering the intersection between the economic, social, philosophical and utilitarian side of bioethics when applied to health care. Admiration for the book comes from the author’s passion that we re-examine the functionality of bioethics as “a kind of short-term risk management science whose experts are uninterested in the nature of the problems they confront, only in their piecemeal confrontation” (p 105).

While it should be axiomatic to assume that bioethicists will by now form a group concerned mainly with advancing their own interests, I do wonder about:
1) “Who benefits presenting scarcity as a natural state in health care?” I don’t understand that sentence, but scarcity will always be a natural state in health care as long as doctors expect to be paid for their work. (And nurses, pharma companies and so on.)
2) ” Who killed the Hippocratic Oath?” Cock Robin, probably.
3) ” Why are doctors portrayed as paternalistic?” Portrayed by whom?
4) “Why has patient care become a secondary concern to budgetary constraints?” Patient care is an objective: a budgetary constraint is just a constraint. These are different things: I don’t see what “secondary” has to do with it. Put otherwise: a secondary concern to whom? Of course, if doctors were willing to work for no pay, budgetary constraints would briefly relax – see point (1) above.

Tom Koch

I appreciate Mr. Rivers’ careful read and consideration of this work. And he certainly gets–and apparently appreciates–its central theme. At the heart of bioethics is an economic perspective and a reliance on the status quo that has little to do with ethics and everything to do with …bioethics position in the world. That said, I note his criticism over my failure to adequately present a discussion of Principlism. While I considered it I’ve noted, in recent years, its disavowal by many bioethicists. To do as he would have asked would have required a full chapter on Principlism and the means by which its elements have been maintained even among those who insist their intellectual alleigance lies elsewhere (communitarianism, feminism, utilitarianism, etc.). I didn’t have space for that in this volume. Perhaps the next.