Principles: A Revolutionary Manifesto in the Guise of a Textbook

As pioneering bioethicist Jonathan Moreno aptly observes, through eight editions of their now classic work, Principles of Biomedical Ethics, Tom Beauchamp and James Childress “shaped a field…and helped to institutionalize that field around the world. It is hard to imagine what bioethics would be like without Principles of Biomedical Ethics” (hereafter referred to as Principles). Footnote ² The impact of Principles is due in no small measure because it was a revolutionary manifesto in the guise of a textbook. Like other revolutionary manifestos, Principles opens by challenging the then common practice of treating ethical issues in biomedicine as a “series of problems, such as abortion, euthanasia…research involving human subjects.” Principles replaced this episodic treatment using just four principles to “apply to a wide range of biomedical problems.”Footnote ³ Three of these principles reinterpreted statements of physicians’ duties found in earlier canonical works of Western medical ethics: the duty of not harming patients became the principle of nonmaleficence; the duty of helping the sick became the principle of beneficence; and the duty of acting justly toward the sick became the principle of justice. Supplementing this traditional trio was a fourth principle new to canonical works in Western biomedical ethics, the duty to respect patients and research subjects as autonomous agents.Footnote ⁴

Deploying these principles Beauchamp and Childress challenged the scientistic paternalism then dominant in American medicine.Footnote ⁵ As the eminent sociologist Talcott Parsons observed, medical practitioners of that period believed that “Non- and irrational mechanisms were…prominent in the reactions of sick people to their situation.” Accordingly, since “the physician is trying his best to help the patient… [the physician–patient relationship] has to be one involving an element of authority… of ‘doctor’s orders’ … [which it is] the patient’s obligation faithfully to accept.” Thus, since the physician is “a technically competent person whose competence and specific judgments and measures cannot be competently judged by the layman. The latter must therefore take these judgments and measures ‘on authority.”’Footnote ⁶ So conceived, the medical ethics of scientistic paternalism presupposed the decisional incapacity of patients and families who were deemed so nonrational in the face of illness, or so ignorant of their own self-interest, that they were incompetent to make medical decisions. Biomedical practitioners, in contrast, as benign scientific agents could make rational medical decisions on patients’ behalf. Thus, the physician’s role was to direct care of the patient and the role of sick patients, and their families, was to dutifully follow doctors’ orders.

Beauchamp and Childress’s principle of autonomy challenged the scientistic paternalist conception of the patient–practitioner relationship by requiring physicians to inform patients and families about the nature of proposed treatments and by empowering patients (or research subjects) to refuse treatment (or to decline participation in experiments). Just as importantly, Beauchamp and Childress expanded the scope of the then-dominant physiological conception of beneficence and nonmaleficence (i.e., not harming) to include patients’ or subjects’ “important and legitimate interests,” in relation to the family, their religion, or other concerns.Footnote ⁷ The effect was to issue a revolutionary manifesto in the seemingly innocuous guise of a biomedical ethics textbook.

As is typical of revolutionary manifestos, Principles was responding to a sense of malaise and discontent arising as the public began to question and reject the subservient sick role assigned to them by the scientistic paternalist conception of the physician–patient relationship. As founding bioethicist Robert Veatch observed, this malaise and discontent became more intense the more laypeople learned about American healthcare practices in the 1970s.

In 1973 a well-publicized manifestation of this discontent embarrassed the American Hospital Association (AHA) into placating the Boston Women’s Health Book Collective (BWHBC), the National Welfare Rights Organization, and various African American civil rights groups into signing A Patient’s Bill of Rights. The focal point of this joint protest was the “condescending, paternalistic, judgmental and noninformative” treatment of women and minorities in American clinics and hospitals.Footnote ⁹ Among the many practices that protestors found objectionable was that of routing the indigent elderly, unwed mothers, and various poor folks into separate hospital and clinic entranceways—and, in the American South, into entrances reserved for Colored or Negro patients. Although the civil rights, Medicaid, and Medicare laws enacted in the1960s had prohibited such discriminatory practices, when these newly entitled patients showed up at clinics and hospitals, they still found themselves directed to the same old entranceways, where they received the same inequitable access and condescending, paternalistic, judgmental, sexist, racist, and noninformative treatment that had been accorded them previously. It was commonplace, for example, to refuse patients treated in former charity, Colored/Negro, and/or welfare clinics the courtesy of advance appointments. Literally and symbolically, American healthcare facilities frittered away their time as if their time—or they themselves—were of little value. Not surprisingly, therefore, when these groups consolidated their demands in A Patient’s Bill of Rights, Article 10 stipulated that every patient “has a right to know in advance what appointment times and physicians are available.”Footnote ¹⁰

Among the other rights that the AHA pledged to respect were the right to have diagnoses, prognoses, and treatment options explained in language patients could understand; the right to be told whether a treatment was experimental; the right to refuse treatment; and the right to be informed of physicians’ conflicts of interest. Yet, even as the AHA publicly endorsed these rights, it appended the following statement indicating that its pledge of reform was merely pro forma since “No catalog of rights can guarantee for the patient the kind of treatment he has a right to expect.” Why not? Because, as the AHA explained condescendingly, “A hospital has many functions to perform, including the prevention and treatment of disease, the education of both health professionals and patients, and the conduct of clinical research.”Footnote ¹¹ Ultimately the AHA’s inactions spoke louder than is words: it made no attempt to enforce the rights that it had been embarrassed into endorsing. Thus, 6 years later, when Beauchamp and Childress published Principles, American hospitals were still cloaking their ongoing ageist, classist, racist, and sexist practices under the mantle of benign scientistic paternalism.

Rejecting the Hobgoblin of Foolish Consistency

In the first edition of Principles, Beauchamp and Childress quote Ralph Waldo Emerson’s remark that “A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines.”Footnote ¹² Emerson’s maxim is often cited by revolutionaries because, as Thomas Kuhn observes of scientific revolutions, “The success of a [new] paradigm is at the start largely the promise of success.”Footnote ¹³ By any measure, Beauchamp and Childress’s approach to biomedical ethics was a promising new paradigm that would prove extraordinarily successful. One factor favoring its success was our intellect’s abhorrence of vacuums: irrespective of whether an insurrection is moral, political, or scientific, it seldom disestablishes an entrenched system of authority, theory, or morality without substituting an alternative conception that holds the promise of resolving issues apparently unresolvable by established conception. Thus, as the failure of the Patient’s Bill of Rights protest illustrates, the benign paternalistic conception of the practitioner–patient relationship could not be displaced without some alternative. Principles laid out that alternative.

Revolutionary new conceptions, like the one laid out in Principles, are typically promissory pronouncements whose proponents can tolerate seeming inconsistencies by putting them aside as matters to be resolved in at some future time.Footnote ¹⁴ One famous example of revolutionaries’ tolerance for inconsistencies in revolutionary manifestos occurred in 1776 when the second Continental Congress tasked Thomas Jefferson with transforming its list of complaints about the British government’s “abuses and usurpations” into a declaration of independence. Recognizing the insufficiency of simply confronting the British government with a list of grievances, Jefferson prefaced congress’s list of complaints with 55 words inspired by English philosopher John Locke: “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty, and the pursuit of happiness. That, to secure these rights, governments are instituted among men, deriving their just powers from the consent of the governed.”Footnote ¹⁵ Using just 55 (of Locke’s) words Jefferson inverts the monarchical presumption that subjects’ role is to serve their superiors, that is, royals and the aristocracy, asserting that all men are equal at the point of their creation. Thus, the proper role of governments is protection of citizens’ creator-conferred unalienable rights to life, liberty and the pursuit of happiness. Consequently, Jefferson concludes, “whenever any form of government becomes destructive of these ends, it is the right of the people to alter or to abolish it, and to institute new government, laying its foundation on such principles, and organizing its powers in such form, as to them shall seem most likely to effect their safety and happiness.” Jefferson then lists congress’s complaints about British actions so destructive to governance that they warrant a revolution.Footnote ¹⁶

Jefferson, a slave-owner who nonetheless advocated the abolition of slavery, also recognized the inherent inconsistency of a nation of slave-owners proclaiming liberty rights.Footnote ¹⁷ Hence, in his original draft, he assuaged the hobgoblin of consistency by blaming the British king for “violating [people’s] most sacred rights of life and liberty in the persons of a distant people who never offended him, captivating and carrying them into slavery in another hemisphere or to incur miserable death in their transportation thither.”Footnote ¹⁸ However, congressional delegations from slaveholding states objected to including a condemnation of the slavery in the Declaration. So, consistency yielded to pragmatism and the passage on slavery was deleted. Revolutionary change was not to be held hostage to the hobgoblin of consistency.

Neither were Beauchamp and Childress. In the first three editions of Principles, they had justified their principle-based account of biomedical ethics by citing a convergence of ethical theories.Footnote ¹⁹ In the fourth edition, however, they recognized some “very probing and often penetrating” criticisms from common morality theorists.Footnote ²⁰ On reflection they decided that justifying principles by citing abstruse ethical theories had made them “invariably more contestable than the norms in the common morality…. For more social consensus exists about principles and rules drawn from the common morality (e.g., our four principles) than about theories.”Footnote ²¹ Capitulating to their common morality critics they jettisoned their original convergence of ethical theories foundation in favor of “unit[ing] principle based common-morality ethics, with [a] coherence model of justification…[to] construct principles and rules from considered judgments in common morality.”Footnote ²² And, indeed, their version of common morality theory gained influential adherents, like Ruth Macklin, who envisioned it as foundational for global bioethics and who used it to critique sexist practices in non-Western countries.Footnote ²³

By its eighth edition Principles was characterizing common morality as offering the

It was also claimed that “No evidence known suggests that societies have handled moral problems by either rejecting or altering basic norms in the common morality.” It was noted, however, that the scope, interpretation and specification of the norms of common morality may vary in particular moralities.Footnote ²⁵

Four Challenges to Common Morality Theories

As formulated in the eighth edition of Principles, common morality theory faces at least four significant challenges. (1) It is unfalsifiable: The claim that common morality is, as a matter of empirical fact, commonly shared by all rational persons committed to morality at all times and all places is unfalsifiable because counterexamples are dismissed as either irrational deviations or failures to live lives committed to morality. If, however, it is claimed to be true by definitional fiat, it is still insusceptible to empirical falsification since definitional truths cannot be falsified. Thus, common morality theorists appear to be propounding an unfalsifiable claim as if it were an empirical observation. (2) It is unempirical: Not surprisingly therefore, no anthropological or historical data has been adduced supporting the claim that “the common morality” is common to all moralities. (3) It is the artifact of a category mistake: the conflation of common areas regulated by moral norms with common norms regulating moral conduct. This conflation enables proponents to reify and elevate late twentieth century American liberal morality to the status of atemporal transcultural universal moral truths that are used to critique alternative conceptions of morality past and present. (4) However, the theories atemporality and claims of transculturality render it useless for analyzing moral change—moral progress, regress, reform, evolution, devolution, or revolution—or for deconstructing the forms of structural discrimination that proponents of A Patient’s Bill of Rights sought to remedy, or for developing global solutions to ethical issues in the context of cultural differences in conceptions of morality. Since criticisms 1 and 2 have been effectively explored by othersFootnote ²⁶; this paper focuses on criticisms 3 and 4.

Common Morality: Reifying a Category Mistake into a Universal Morality

Common morality theorists claim to have discovered a universal morality valid in all cultures, at all times, and in all places, rests on a category mistake: the conflation of areas of conduct commonly regulated by moralities (e.g., killing people) with common regulations embraced by all societies at all times and places (e.g., killing murderers is morally permissible). It is true that virtually all societies regulate killing fellow humans; however, they do not have the same substantive rules regulating killing fellow humans. Some societies hold that is morally permissible for men to kill other men in duels defending their honor, or for men to kill women to redeem a family’s honor.Footnote ²⁷ Then again, some societies believe it is morally permissible for individuals to exact retribution taking life for life (as in Leviticus 24:19–21); others believe that retributive justice is the sole prerogative of governments; still others hold human life so precious that not even governments have a right to kill murderers. And some societies believe that human life should be respected from the moment of conception, whereas others permit aborting the life of a zygote, embryo, or fetus, if it endangers maternal life or health, or, if it was conceived through rape or incest, or if it is likely to be disabled, or simply because it is unwanted.

It is true that societies commonly regulate killing; however, to reiterate, they do not share some one common moral standard with respect to when or which humans may or may not kill fellow humans. To restate this point on a more prosaic level: societies commonly regulate the flow of traffic in their cities, but they have different traffic regulations (e.g., on which side of a street to drive on). To confound the common practice of regulating traffic with substantively common regulations governing traffic flow would be what philosophers refer to as a “category mistake.” And when common morality theorists claim to have discovered “universal norms shared by all persons committed to morality, the common morality….applicable to all persons in all places, and we appropriately judge all human conduct by its standards,”Footnote ²⁸ they are reifying a category mistake into a universal moral standard. Compounding this error, some claim that since the universal moral norms of common morality are “open to all rational persons in all societies at all times they are unchanged and unchanging, discovered rather than invented…. general moral rules [that] apply to all rationality persons at all times, obviously they cannot be invented, or changed.”Footnote ²⁹ Beauchamp and Childress concur, albeit on the quasi-empirical grounds that, “No evidence known to us suggests that societies have handled moral problems by either rejecting or altering basic norms in the common morality.”Footnote ³⁰

Common morality theorists admit that some moral norms have changed over time, acknowledging that the moral permissibility of enslaving people has changed. However, Beauchamp and Childress claim that since “slave owning clearly violate[s] respect for autonomy and nonmaleficence introduction of a rule allowing this practice would leave the common morality in a state of moral incoherence, whether or not slave-owning societies recognize this fact.”Footnote ³¹ This is an odd statement coming from common morality theorists insofar as they are asserting the empirical claim that common morality consists of universal norms shared by all persons committed to morality. This would seem to imply that, given the near-universal acceptance of slavery prior to the nineteenth century, either people living in earlier times did not live lives committed to morality, or that it is empirically false that people at all times accepted the so-called “common” morality. In point of historical fact, moral condemnation of slavery was so controversial that it took two revolutions and a civil war—a political revolution in France (1789), a moral revolution in Britain (1833), and a civil war in the United States (1861–1865)—to establish the immorality and illegality of slavery in the Western world. Global condemnation of slavery was not achieved until the twentieth century.Footnote ³² It would appear that, whatever common morality theorists mean by “common morality,” they are not referring to some substantive morality commonly accepted by all persons committed to morality throughout recorded history. It seems more likely that they are projecting a view of morality “common” among American liberals in the late twentieth century onto other periods and cultures. In effect, this reifies late twentieth century American liberals’ sense of morality from a term of persuasion or an (historically inaccurate) empirical-appearing observation into a metaethical standard for ascertaining the validity of all other conceptions of morality, that is, it converts it into a form of moral imperialism.

They also claim that “slave owning clearly violate[s] respect for autonomy and nonmaleficence [and thus] is not coherent with [common morality’s] principles and cannot be specified to be coherent with them.”Footnote ³³ This seems odd because, in point of historical fact, until the late eighteenth century major Western philosophers— Plato, Aristotle, and even Enlightenment philosophers, like Locke—believed that slavery was compatible with nonmaleficence. They reasoned that the custom of enslaving captured enemies was less harmful than the alternative practice of committing genocide on captive populations (or, at least, the male portion of that population).Footnote ³⁴ Moreover, Aristotle, who was a Greek supremacist, “believed that non-Greeks (βάρβαροι [barbarians]) are natural slaves,” because their outward appearance, that is, their skin color, differs from that of Greeks.Footnote ³⁵ Plato also rejected the application of nonmaleficence to the treatment of slaves, holding that “just” treatment of slaves requires one to be harsh, that is, “One must punish slaves justly, not spoiling them by admonition as though they were freemen.”Footnote ³⁶

It is even more puzzling to reject “slave owning” on the grounds that it “clearly violate[s] respect for autonomy,”Footnote ³⁷ since neither Plato, nor Aristotle, nor Locke, nor any philosopher writing prior to Kant, could have understood this claim. They would have understood autonomy in the original Greek sense of political self-governance—a property that conquered peoples lose by virtue of having been conquered. Immanuel Kant first introduced the concept of moral autonomy to the Western philosophical lexicon in the late eighteenth century. Prior to Kant’s epiphany, however, almost all European philosophers of the Enlightenment were white supremacist who accepted colonialism and slavery as a natural consequence of the white man’s moral, cultural, military, and technological superiority. As late as 1782 Kant himself was writing that Native “Americans and Negroes cannot govern themselves [and could] serve only as slaves.”

Yet conceptions of morality evolve and, as Kant explored the implications of his newly formed concept, autonomy, he “abandoned the thesis of racial hierarchy and white superiority” and “began to criticize colonialism and slavery, … simultaneously add[ing] a new …cosmopolitan right [which] grants full and equal juridical status to all humans—to all ‘citizens of the earth.’”Footnote ³⁸ To sum up (using a Sellarsian rendition of a Kantian dictum): insofar as percepts without concepts are blind,Footnote ³⁹ prior to his reconceptualization of autonomy as moral self-rule, Kant himself was blind to the immorality of white supremacism, colonialism, racism, and slavery. Furthermore, since, as Kant once observed, “the action to which the ‘ought’ applies must indeed be possible under natural conditions,”Footnote ⁴⁰ Kant could not blame himself—nor should we blame him—for his earlier white supremacist acceptance of slavery and colonialism in the 1880s. For neither Kant, nor any other Western philosopher writing previously, could conceive of racism or slavery as incompatible with a concept that had not yet been conceived. The limits of Kant’s conceptions set the limits of his moral vision; as it does for everyone. Thus, insofar as what it means to live a life committed to morality is limited by the morality one can conceive, we cannot blame others for living lives that they believed were moral—even though we consider their actions immoral—if their understanding of morality differs from ours. We can and should, however, condemn their practices as immoral because our moral worldview has been expanded by concepts of human rights, and, for the philosophically well-versed, by Kant’s conception of autonomy. To reiterate for clarity and emphasis, although we should not blame slaveholders of earlier eras for failing to live a life committed to morality, insofar as we hold that all people have unalienable rights to life and liberty, we can and should condemn enslaving or owning slaves—past or present—as an immoral violation of the rights of those enslaved.

We can also critique other views of morality, past or present, as deficient in achieving the fundamental objectives for which societies create moralities: to facilitate cooperation and to minimize conflict within and between communities. This applies to enslaving others for, as Locke himself fully appreciated, “the perfect condition of slavery…is nothing else, but state of war continued between a lawful conqueror and a captive.” Thus, to enslave people is to perpetuate war-like conflict within the context of a civil society, thereby creating ongoing internal tension that can foil one of the most fundamental objectives of morality, establishing civil tranquility.Footnote ⁴¹

Duties, Principles, and Common Morality Theory

Moralities change over time, sometimes by evolution, sometimes by drift, sometimes though moral reforms and sometimes through moral, political, or economic revolutions. These changes are usually marked by the introduction of new conceptions and terminology and, insofar as attempts at moral change are successful, they are typically accompanied by the obsolescence or reinterpretation of traditional moral concepts and terminology and by pressure to reform or abandon the practices they once justified. A case in point is Principles’ introduction of autonomy into American medical ethical lexicon. This concept offered conceptual support and validation of protestors’ claims in A Patient’s Bill of Rights (which was appended in full to the first edition of Principles Footnote ⁴²). Some may bridle at the notion that so humble an object as a textbook can have a revolutionary impact on medical morality. Yet a moment’s reflection should make it evident that textbooks serve as a means by which one generation—in this case, a revolutionary generation—is a vehicle for transmitting whatever that generation takes to be important to successor generations. To emphasize this point, and to underline the significance of conceptual innovation, it is instructive to compare Principles with a very different revolutionary manifesto published as a medical ethics textbook: Rudolf Ramm’s 1943 Physicians’ Duties and the Rules of the Medical Profession (Ärztlizche Rechts-und Standeskunde Der Artz als Gesundheitserzieher, hereafter referred to as “Duties”).

Duties, like Principles, explains and justifies a revolutionary new conception of biomedical ethics: that of the National Socialist German Workers Party (Nationalsozialistische Deutsche Arbeiterpartei, hereafter, NSDA).Footnote ⁴³ The NSDSA condemned traditional entrepreneurial and professional conceptions of medical practice because, they claimed, these conceptions had left German physicians financially and morally bankrupt and had contributed to the declining physical and genetic health of the German Volk (i.e., a people connected to each other genetically and culturally).Footnote ⁴⁴ Consequently, “Even though the ultimate responsibility goes to the healing of patients and the perpetuation of life,” the NSDA proposed “an essential expansion” in physicians’ duties “through coming to grips with biological thinking in the National Socialist state.”Footnote ⁴⁵

This expansion was predicated on the concept of Rassenhygiene (Racial Hygiene). This concept was not new to the German medical lexicon. Alfred Ploetz had introduced it in 1895.Footnote ⁴⁶ What was new was the NSDA’s adoption of Rassenhygiene as official government policy.Footnote ⁴⁷ Thus, Duties informs medical students, after they become physicians they will be responsible for promoting healthy eating (of whole grain breads, for example), and for discouraging the use of tobacco (as carcinogenic).Footnote ⁴⁸ They must also obey “law[s] for the reestablishment of German blood…for Prevention of Genetically Ill Offspring…for the Defense of the Genetic Health of the German Volk… which prohibits for all time a further mixing of pure-blooded German people with the Jewish and lower races. The Sterilization Law [also] preclude[s]…genetically ill and morally inferior people from transmitting their genes.”Footnote ⁴⁹ Thus they would also be required to report children and adults with disabilities to hereditary courts (that would refer them to specialized institutions, such as Hadamar psychiatric hospital, where they would be covertly killed).Footnote ⁵⁰ And indeed, during this period famous physicians, like Johann Asperger, discoverer of the eponymous “Asperger’s syndrome,” did in fact report children with disabilities to the authorities.Footnote ⁵¹

Duties, it should be clear, was the official textbook of NSDA, or “Nazi,” medical ethics. It was used in a required course for upper-level German medical students from 1942 to 1945.Footnote ⁵² Some might find the expression “Nazi medical ethics” objectionable on the grounds that no text propounding the ableist, anti-Semitic, homophobic, and racist views that culminated in the Holocaust can properly be given the title “ethics.” Yet if we are to understand and analyze the nature of morality, we cannot treat the concept, “ethics,” as an honorific applicable only to justifications of our own moral beliefs, or those consistent with them. We need to recognize that the concept and term “ethics” applies to any attempt to justify whatever some person, movement, community, or society believes to be moral or immoral. In this sense, Duties was the medical ethics textbook of Nazi Germany in the same way that Principles was the ethics textbook of late twentieth century American bioethics, that is, to use a criterion employed in Principles, both books address the questions “Which general moral norms should we use to guide and evaluate conduct and why?”Footnote ⁵³

In answering these questions Duties presents a coherent account of the conception of biomedical ethics that led German physicians to become complicit in the Holocaust. For example, when, reporters pressed, Dr. Karl Brandt, director of the Aktion T4 program for killing children with disabilities, he justified his actions with a statement that could have been taken directly from the pages of Duties. “We German physicians look upon the state as an individual to whom we owe prime obedience. We therefore do not hesitate to destroy an aggregate of, for instance, a trillion cells in the form of a number of individual human beings if we believe they are harmful to the total organism—the state.”Footnote ⁵⁴ Brandt’s explanation was not idiosyncratic. When psychiatrist Robert J. Lifton interviewed physicians who had staffed concentration camps (like Auschwitz), he too found that they expressed no signs of remorse because they accepted “the principle of ‘racial hygiene’ [Rassenhygiene, and were] working toward a noble vision of the organic renewal of a vast ‘German biotic community’…with a positive mission involving the principle of “the necessity to ‘sweep the clean the world’.…in the words of their leader,” Adolf Hitler, ‘to see to it that the blood is preserved pure and by preserving the best of humanity, to create the possibility of a nobler development.’” Footnote ⁵⁵

Moral innovation often hinges on pivotal concepts, like autonomy, or in this case, Rassenhygiene, that allow a reinterpretation of established moral norms. As imparted in Duties, for example, many of a physician’s duties are similar to those cited in more conventional Western medical ethics statements of the 1940s. Thus, physicians are said to have a duty to respond to the medical needs of the poor and rich equally, to preserve medical confidentiality, and to perform abortions “only if there is a danger to the life of the pregnant woman.”Footnote ⁵⁶ What transforms these otherwise commonplace statements into Nazi medical ethics is the impact of Rassenhygiene, a concept that expands the scope of physicians’ responsibilities to include future generations. Thus, “Whoever weakens the Volk community through abortion of a fetus is to be placed on the same plane as a traitor to the country and Volk.”Footnote ⁵⁷ A similar line of reasoning leads to an absolute prohibition against practicing euthanasia on any member of the Volk. Footnote ⁵⁸ Yet everything is different with respect to the treatment of non-Volk. As Brandt and Ramm underscore, Rassenhygiene also justifies eugenic prohibitions for the prevention of genetically ill offspring, and for the defense of the genetic health and purity of the German germline as viewed through the ableist, anti-Semitic, and more generally racist lens that culminated in the Holocaust.Footnote ⁵⁹

In striking contrast, by its fourth edition Principles had extended its interpretation of “autonomy” and its redefinition of “beneficence/nonmaleficence” to embrace all humanity. One might even be tempted to suggest that the universalist and humanistic conception of medical morality evident in all eight editions of Principles (and in the work of other common morality theorists like Gert, and Macklin) was a reaction to the narrowing of the scope of medical morality evident in the ethics of Rassenhygiene. An unfortunate consequence of any such reaction is that, having fettered their principles to an atemporal transcultural universal ethics, they were forced into making empirically false claims, such as, “Violation of these norms [of common morality] is unethical and will generate feelings of remorse.” Footnote ⁶⁰ In point of historical fact adherents of Rassenhygiene, like Karl Brandt, never exhibited remorse for implementing programs like Aktion T4.

Perhaps more to the point, throughout his life Brandt sought to live a life committed to morality. As a young physician he applied to work with Albert Schweitzer’s medical mission but was prevented from traveling to Africa by bureaucratic obstacles.Footnote ⁶¹ Brandt also studied with liberal psychiatrist Alfred Hoche, co-author of an influential treatise published in 1920, The Release and Destruction of Lives Unworthy of Being Lived (Die Freigabe der Vernichtung lebensunwerten Leben).Footnote ⁶² Brandt’s biographer, Ulf Schmidt, writes that “Hoche—and later Brandt— applied British sociologist Herbert Spencer ‘s concept of the social organism to the mentally ill.” They “saw the state as an organic entity in which the mentally ill were parts of the ‘body politic’ (Volkskörper) that had been damaged, useless, or harmful and needed to be removed….[and this]…provided the intellectual and moral basis from which Brandt would later argue his case after Hitler had asked him to implement [Aktion T4] and also during the Nazi Doctor’s Trial [at Nuremberg].”Footnote ⁶³

Brandt was not the only unapologetic German physician of that era: lack of remorse was so widespread among German healthcare professionals in the immediate postwar era that when the World Medical Association (WMA) made legitimization of the German medical profession contingent on a statement of apology and contrition, the organization representing (West) German physicians (the Arbeitsgemeinschaft Westdeutscher Artzekammern [AWA]) refused to apologize or to act contrite. The WMA was “astonish[ed] … that no sign whatever had come from Germany (the AWA) that the doctors were ashamed of their share of the crimes, or even that they were fully aware of the enormity of their conduct.”Footnote ⁶⁴ Eventually AWA apologized, but it did so unwillingly.Footnote ⁶⁵ Thus, contrary to the claim laid out in Principles, German physicians like Brandt were committed to living a moral life, they believed their role in the Holocaust was ethical and they did not have “feelings of remorse” about it. As Schmidt put this point, “In the worldview of Brandt and other Nazi physicians…they genuinely believed that their actions could be justified on the basis of what they perceived as their noble motivation. …. As [Brandt] later defended his actions at Nuremberg [he] never felt that it was not ethical or was not moral.”Footnote ⁶⁶

In contrast, when a Turkish physician was asked whether by participating in the genocide of Armenians (1914–1923, 1.5 million killed) he had violated his medical calling he replied, “My Turkishness prevailed over my medical calling.”Footnote ⁶⁷ The physician then analogized his genocidal acts to preventing the spread of pathogens. “Armenian traitors had found a niche for themselves in the bosom of the fatherland: they were dangerous microbes. Isn’t it the duty of a doctor to destroy these microbes? …I shut my eyes and surged forth without reservation.”Footnote ⁶⁸ The Turkish physician’s remarks about pathogens were metaphorical. The point to appreciate is that one innovative concept, Rassenhygiene, transubstantiated the Turkish doctor’s metaphor into a literal “truth” that reconciled German physicians’ medical ethics with their complicity in genocide.

Concluding Observations: The Limitations of Common Morality Theory

Differences in morality are a fact of life. Our medical ethics contains no commitment to Rassenhygiene; to the contrary, thanks in large measure to Principles, our medical ethics is predicated on a concept of autonomy. There is a world of difference between contemporary bioethics and Nazi medical ethics. Yet taking refuge in a purportedly universal atemporal morality forfeits the very conceptual tools required to analyze the types of conceptual change that culminate in moral change, including the racially infused eugenicist moral revolution implemented by the National Socialists in German medicine during the first half of the twentieth century. Nor, for that matter, does common morality theory offer philosophers, bioethicists, or other healthcare professionals, the conceptual tools for deconstructing or grappling with the very aspects of the American healthcare that motivated A Patient’s Bill of Rights: systemic ageism, classism, racism, and sexism—or the enduring issues of ableism, anti-Semitism (anti-Muslimism), ethnocentric discrimination (e.g., white supremacism), and gender discrimination (e.g., against LGBTQ+ patients and people). Mainstream American bioethics’ inability to grapple with these issues may explain the formation of subgroups within bioethics organizations that focus on disability rights and genocides, as well as Jewish, feminist, and LGBTQ+ ethics—all areas by and large untouched in Principles.

As philosophers and bioethicists, we need to study diverse moralities, especially those of societies, present and past, whose moralities and ethics are incompatible with our own—even those repugnant for us to contemplate. Fettering our analyses of morality to a single set of paradigms, concepts, norms, or laws, limits our ability to analyze the processes of moral experimentation, moral reform, and moral revolution that enables societies to alter their moral paradigms, concepts, and norms. At a deeper level, analyzing the success of some moral changes and the failure of others gives us some purchase on what makes some moralities more effective at achieving the minimal objectives of any morality, that is, facilitating social cooperation within and between communities and preventing or minimizing social conflict. Blinding ourselves to the history and diversity of moralities inhibits our ability to analyze and to respond effectively to the morally disruptive innovations and epidemiological, climatological and socioeconomic challenges that unavoidably await us.