When is it justifiable for us to inflict pain on others? Historically, the principle of medical utility – to maximise pleasure and minimise pain for the greatest number – has justified experimentation with human subjects as sacrifices on the altar of scientific knowledge. To harm the incurable, the isolated poor or the racially different in the pursuit of medical knowledge to benefit those that come after their sacrifice is a common theme in the history of medical ethics from Nuremberg to Tuskegee. In the wake of the Nazi Doctor’s Trial at Nuremberg and the attempts to prevent the unethical exploitation of patients and minorities during the Cold War, medical utility lost its ethical primacy to the principle of informed consent. In this captivating new book, Cathy Gere compellingly argues that what has arisen in the ethical debates concerning these two principles is not a question of good versus evil, but a historical antagonism between two divergent ideas of the good. The antagonism between these two principles of the good has been marked by a shift in the moral superiority of one over the other. Between informed consent and medical utility, the question posed by doctors, legislators and ethicists since the end of the Second World War has been which of the two principles holds legitimate moral primacy over the other? Which of the two principles is the driving moral absolute that should guide the conduct of doctors?
In Pain, Pleasure and the Greater Good, Cathy Gere charts across time the controversial and disputed territory of the antagonism between the principle of informed consent and medical utility. The focus of Gere’s book is the argument, that while many ethicists have striven for the moral high-ground in their denunciations of human experimentation without a patient’s consent as the callous refuge of Nazis and racists, we have missed the important reasons why the ethical antagonism between medical utility and informed consent exists at all. Gere ambitiously declares that if we do not step carefully, we are in imminent danger of once more placing medical utility – the doctrine of the greater good – in the place of moral primate over informed consent. She builds her case upon the excellent scholarship of Jay Katz, Alexander Capron, Eleanor Glass, George Annas, Michael Grodin, Ulf Schmidt and David Rothman, among a host of others – Gere has certainly done her historiographic homework here. She demonstrates that, although the history of the principle of informed consent has been told with distinctly varying emphases, the variety in the historiography itself has exemplified over forty years the changing standards and attitudes concerning the principle of informed consent’s moral primacy. The varying attitudes in the recent historiography are reflective of a longer antagonistic history that has dominated the patient–doctor relationship for over two centuries between consequentialist ethics, typified by arguments from medical utility, and categorical ethics, respectively typified by human rights and the principle of informed consent.
The heart of Gere’s book is concerned with demonstrating the historical dominance utilitarianism had within the Anglo-American world for nearly two centuries before the rise of informed consent. Gere demonstrates the longer history at play between these two varying ideas of the good and their respective roles in the history of medical ethics. In charting this longer history, the book can be separated into three distinct sections. The first, comprising the introduction and the first chapter, cover the history from Nuremberg to Tuskegee that signalled the swan song of medical utility’s fall from grace as the predominant ethical foundation of the relationship between doctors and their patients as experimental subjects. The second section comprises the most substantial historical analysis in the book. Over the course of the three chapters following from the first, this section travels back to the nineteenth century and follows the conception and development of the principle of medical utility out of its utilitarian roots. Gere argues that Jeremy Bentham’s reaction against the metaphysical language of rights that underpinned the French revolution gained a substantial moral triumph when this new British form of ethics stood mighty against the failure of rights in the wake of the Reign of Terror. Though this analysis of utilitarianism’s victory is by no means new, Gere presents a critique of utilitarianism in the following chapter, by arguing the grave distributive inequalities at the heart of utilitarianism. She explores the marriage between Bentham and Malthus in the achievement of the work-house reforms of 1834. She argues these reforms foreshadowed the often-repeated mechanistic means by which utilitarianism can discriminate against the very poorest and most vulnerable in a society. As Gere puts simply, these people are deemed to have the very least to lose and as such are justifiably sacrificial in the pursuit of the greater good. Following from this critique, Gere continues by plotting the development of utilitarianism through the work of John Stuart Mill and Alexander Bain. She concludes that as the nineteenth century ended, utilitarianism and its mechanistic patterns of distribution based on pain and pleasure became the accepted evolutionary model that determined society’s progress by British scientists, economists and philosophers. The final section, comprising the last two chapters, tells of the rise of utilitarian psychology on the other side of the Atlantic, and explores the clandestine re-emergence of utilitarianism in the fields of ‘neuroeconomics’ and ‘behavioural economics’, and the close ethical foundations these new disciplines share with the Cold War principles of medical utility.
Written with verve and character, where the author’s voice is unapologetically present, Gere’s new book provides a stylishly forceful critique of medical utilitarianism. Her aim to uncover, critique and expose the dichotomy between pain and pleasure that drives utilitarian ethics, and its mechanistic apportioning of human society into categories of social needs and the individual’s sacrificial value, is comprehensive and thought-provoking. This is an important new addition to the history of informed consent and medical ethics, and as a provocative and thoughtful work it stands as a must read for historians of medical ethics, bioethicists and medical practitioners alike.
