John Gregory and the Invention of Professional Medical Ethics and the Profession of Medicine

The best things in my Ufe have come to me by accident and this book results from one such accident: my having the opportunity, out of the blue, to go to work as H. Tristram Engelhardt, Jr. 's, research assistant at the Institute for the Medical Humanities in the University of Texas Medi­ cal Branch at Galveston, Texas, in 1974, on the recommendation of our teacher at the University of Texas at Austin, Irwin C. Lieb. During that summer Tris "lent" me to Chester Bums, who has done important schol­ arly work over the years on the history of medical ethics. I was just finding out what bioethics was and Chester sent me to the rare book room of the Medical Branch Library to do some work on something called "medical deontology. " I discovered that this new field of bioethics had a history. This string of accidents continued, in 1975, when Warren Reich (who in 1979 made the excellent decisions to hire me to the faculty in bioethics at the Georgetown University School of Medicine and to persuade Andre Hellegers to appoint me to the Kennedy Institute of Ethics) took Tris Engelhardt's word for it that I could write on the history of modem medical ethics for Warren's major new project, the Encyclopedia of Bioethics. Warren then asked me to write on eighteenth-century British medical ethics.

John Gregory was a Scottish physician who taught at the famed medical school of the University of Edinburgh in the latter half of the 18th century. Scion of a family of renowned mathematicians, he moved in the company of brilliant minds, such as David Hume and his own cousin, Thomas Reid, who lit the intellectual movement known as the Scottish Enlightenment. Although overshadowed as a professor of medicine by the great William Cullen, Gregory attained respect for his learning, his clinical skill, his kindness, and particularly for his Lectures on the Duties and Qualifications of a Physician (London, 1772). These lectures were translated into several languages and brought to the United States by one of Gregory's students, Benjamin Rush of Philadelphia.

McCullough has drawn Gregory out of the shadows of the history of medicine by editing his writings and by authoring this biography. The interest in medical ethics during the past several decades has exposed our sad ignorance of the history of the field. More than one scholar has noticed what Andrew Wear calls the "gap that exists between the oft-cited `origins' of medical ethics, the Hippocratic Oath and Thomas Percival's Medical Ethics of 1803" (Doctors and Ethics. Atlanta: Rodopi, 1993). That gap is slowly being bridged, and McCullough's double work is a valuable contribution. Ironically, it was Percival's Medical Ethics (London: J. Russell), which was imported almost whole into the first code of ethics of the American Medical Association (AMA) in 1847, that cast Gregory's earlier thoughts about medical ethics into the shadows. Even though Percival himself, an English physician of the generation after Gregory's, acknowledged Gregory's "excellent lectures," and the AMA drafters were familiar with his work, Gregory almost disappeared from the historical scene. Yet, as McCullough argues, his views of medical ethics are in some ways more congenial to our contemporary understanding of the ethical relationships between physicians and patients than those of the more prestigious Percival or the founders of the AMA.

McCullough demonstrates clearly that one feature of modern medical ethics -- the acknowledged utility of philosophical ethics in the formulation of medical ethical responsibilities -- was a major part of Gregory's thought. He found in Hume, Reid, and other philosophers of his milieu an idea that linked philosophical ethics and medical work: the fundamental notion of sympathy. The philosophers had elaborated on the natural ability of humans to appreciate the feelings of one another; the physician drew that idea into the work of those who were responsible for people who were suffering. In so doing, he was able to weave his thoughts about medical ethics around a widely acknowledged philosophical notion. The sick person was raised from an object of attention to a subject whose feelings the physician could share. Although hardly achieving the modern ethical thesis about the autonomy of the patient, Gregory equalized the physician and patient at a fundamental moral level. Gregory also appreciated, much more than most men of his time, the role of women as intellectual and moral models and so anticipated the modern insistence on feminine ethics as integral to general and medical ethics.

The portrait of John Gregory in his cultural, medical, and intellectual world is sketched sharply and brightly. Both books are genuine contributions to the history of medical ethics. However, McCullough proposes that this learned and congenial Scottish physician "invented" professional medical ethics and the profession of medicine. This large claim is not, in my judgment, adequately proved. The medical profession evolved, from the 12th century onward, through the universities, guilds, medical and surgical colleges, and town physicians, and although by Gregory's time it was not quite a profession as we know it, it had many of the essential characteristics. Gregory may have moved professional self-definition slightly ahead with his ideas -- particularly his insight into the fiduciary responsibilities of physicians -- but many other forces were needed to shape the form of medicine that came into being in mid-19th-century America. And it was Percival's thought, more than Gregory's, that articulated the ideals.

McCullough also underestimates the long tradition of medical ethics that had preceded Gregory and of which he was in many ways a part. Unquestionably, McCullough knows that long tradition, but he gives only a skimpy account of it in order that Gregory may appear more inventive. The citations of earlier medical moralists, such as Roderigo de Castro and Friederich Hoffmann, are used to show discontinuities rather than the continuity of thought that could, in my view, just as easily be demonstrated. It is notoriously difficult to compare and contrast philosophically inclined writers, as these medical moralists were, and McCullough has made it too easy to see Dr. Gregory as an innovator. Yet much of the work of the history of medical ethics remains to be done (the works of de Castro and Hoffmann, for example, are untranslated and barely known even to scholars). This biography of a worthy figure in that history and a new edition of his works are welcome.

Reviewed by Albert R. Jonsen, Ph.D.
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