The Patient as Person Explorations in Medical Ethics by Paul Ramsey Yale University Press, 320 pp., $17.95 IN A TIME when war and cloning seem to dominate the news, it is worth recalling the writings of Paul Ramsey–for he spent a decade of his life thinking and writing about just-war theory, and better than another decade helping to shape the emerging field of bioethics. Beyond all that, Ramsey was a larger-than-life figure, hard to forget for all who knew him. Born in Mississippi in 1913, the son of a Methodist minister, Ramsey spent almost all of his academic career teaching at Princeton University. He retired from Princeton’s department of religion in 1982, having taught there for thirty-eight years. After retiring he devoted much of his (always formidable) energy to editing the “Ethical Writings of Jonathan Edwards” for the Yale edition of “Edwards’s Works,” a volume that was published in 1989, a year after Ramsey died. As a teacher and conversationalist, Ramsey could be overpowering. To argue with him was to be forced into constant refinement of one’s view. He would probe, push, and hypothesize in a style uniquely his own–punctuated by puffs on his pipe, by sentences ending “heh?” or “you know?” but not really requiring any answer–as he pressed on with his analysis. If one did manage to get in a few words, Ramsey would go to work again–demonstrating the shortcomings of one’s viewpoint but, at the same time, turning it into a stronger, better argument than it had been. Although he liked to refer to his writing as his “poetry” and was sometimes given to rhetorical flights appropriate to the son of a Methodist preacher, his writing was of a piece with his conversational style. That is, it involved a relentless probing of arguments, always in conversation with the work of other scholars. Ramsey seldom developed his own view straightforwardly; he preferred to unfold it by dissecting, at length and always with gusto, the arguments of others. He was, as a colleague of mine once put it, an “intellectual street fighter.” This can make for heavy going for his readers, especially today when many of his interlocutors may be less well known than they were when he wrote. A reader must be willing to follow the twists and turns of the argument, watching Ramsey dissect the writing of other authors whose work is no longer familiar. Moreover, no one can deny that his “poetry” appeared to others as rather convoluted prose. Ramsey knew this, of course, and could laugh about it. Once he had cards printed up for himself. On one side were his name, degrees, and office address. On the other side was a sentence from a review of his “War and the Christian Conscience”: “Incidentally,” the reviewer observed, “the book is written in a beautifully articulate style which reveals an exceptionally clear and charitable mind, and makes it, in so far as any book on this subject can be, a positive pleasure to read.” Ramsey was not about to let such a rare favorable comment on his prose go unappreciated or unnoticed, and he would pass out the cards, observing that this was “an answer to my detractors.” He was capable of real poetry, though, as when he dedicated “Nine Modern Moralists” to his twin daughters, “individual pearls of equal price.” (That dedication, incidentally but unsurprisingly, captures the heart of Ramsey’s ethic of Christian love: It affirms unconditionally and, hence, equally the being and well-being of each person given into our care.) BECAUSE RAMSEY’S writing is difficult both stylistically and conceptually, one must make an effort to read him. For anyone willing to take the necessary pains, however, the effort will be rewarded. One place to begin is with the collection entitled “The Essential Paul Ramsey” (1994). The editors, William Werpehowski and Stephen Crocco, managed to excerpt portions of Ramsey’s writings in ways that do not require readers to make their way through all the twists and turns characteristic of a Ramsey argument. And their brief introduction provides a helpful starting point. Nevertheless, if one really wants to profit from sustained engagement with his work, there is nothing to be done but to tackle Ramsey whole. To that end, one might well begin with “The Patient as Person,” first published in 1970 and recently reissued by Yale University Press. When Ramsey wrote about subjects such as medicine and war, he always sought to learn as much as he could from specialists in the field. He was an extraordinarily good listener, and he had the kind of mind that could work an issue through from various angles, finding every bit of illumination that was available. In the late 1960s, when he turned his attention to medical ethics just as it was beginning to emerge as a focus of interest and concern in this country, he first held a research appointment at Georgetown Medical School. That research formed the background for the Lyman Beecher Lectures on Medical Ethics that he delivered at Yale in 1969–and those lectures in turn became “The Patient as Person,” by any standard one of the truly influential works in bioethics. Though marked by Ramsey’s poetry at any number of places and, of course, dated in certain respects, it is very readable and still highly relevant. There are chapters discussing the ethics of human experimentation, the determination of death, the donation of organs for transplant from both living donors and cadavers, and the allocation of scarce resources. On all these subjects Ramsey continues to be well worth reading. The third chapter, “On (Only) Caring for the Dying,” is, I think, Ramsey at his very best and remains one of the classic essays in the field of bioethics. The unwary reader should not assume, though, that any of these chapters offers the final word on its subject. Ramsey himself did not believe that, nor was it his intention. He wrote, as he liked to say, “to continue the conversation.” He refined and, even, withdrew some of his arguments in later writings. Indeed, on the topics to which Ramsey devoted the bulk of his energy–especially just-war theory and medical ethics–his later treatments almost always become more convoluted and the arguments ever more complex. The British scholar Oliver O’Donovan has noted this characteristic of Ramsey’s writing and described it nicely: “His first book in each field was a general map-drawing book, identifying the key moral species-terms which Christian tradition offers….The later work in each field takes the reader deep into the task of discernment itself and allows its bewildering complexity to emerge.” Any reader who wants to observe this might consider, for example, the movement from the clear and straightforward discussion of “rules” in “Basic Christian Ethics” (1950) to the more complicated discussion of “Deeds and Rules in Christian Ethics” (1967), to the enormous complexity of argument in “The Case of the Curious Exception” (in 1968 in a volume called “Norm and Context in Christian Ethics”). Or, again, one might look at the increasing complexity of argument as one moves from “War and the Christian Conscience” (1961) to essays in “The Just War” (1968). IN MEDICAL ETHICS, much the same kind of movement takes place from “The Patient as Person” in 1970 to “Ethics at the Edges of Life” in 1978. In 1970 Ramsey had been concerned to oppose medical overtreatment, and he sought to clear space for patients to participate in decision-making and to refuse treatments that were useless or burdensome. At times he seemed to make treatment refusals turn on considerations of quality of life, and he could even write of the possible “choiceworthiness of death.” The basic rule articulated in “The Patient as Person,” shaped by what Ramsey called covenant love, is “never abandon care.” Yet Ramsey was prepared to consider as a thought experiment two circumstances in which one might make an exception to the rule: when a patient is “irretrievably inaccessible to human care,” and when a patient suffers “a kind of prolonged dying in which it is medically impossible to keep severe pain at bay.” In such circumstances, Ramsey thought, if care can no longer be given (because it can no longer be received), the obligation to give it ceases. At that point, it would, he tentatively suggested, be permissible not just to “let die” but also to kill. By the time Ramsey returned to these issues in “Ethics at the Edges of Life,” he had subjected his own earlier positions to continued scrutiny, and he had also taken note of how swiftly the context for medical decision-making was changing. Where a decade earlier he might have worried chiefly about useless or burdensome overtreatment and about patients who were given little say in decisions about their own treatment, he now was inclined to fear undertreatment, especially for those patients whose lives seemed of little worth or who were vulnerable and unable to speak for themselves. Now he worried that, in the name of patient autonomy, physicians might become little more than well-educated technicians placing their skills in service of patient preferences. Now he was alert to the fact that one could not “let die” a patient who was not in fact dying. One could only choose not to treat so that the patient would die. And, without exactly retracting his thought experiment, Ramsey now withdrew the exceptions to the rule “never abandon care” that he had proposed in “The Patient as Person.” IN SHORT, to read Ramsey seriously is to commit oneself to following the twists and turns of his argument over time. This will, however, almost always benefit the reader. For example, anyone paying attention to our society’s current arguments about cloning could profit greatly from reading “Shall We Clone a Man?” (chapter two of Ramsey’s little book “Fabricated Man”). Here one will find reflection that takes us well beyond questions of safety alone, the only sort of issue that our own public debate often seems to understand. Ramsey ponders the significance of cloning for the meaning of human parenthood and the moral importance of the fact that in “natural” procreation the child’s being is the mysterious product of parental self-giving–the result of “doing,” not of “making.” He notes that cloning invites a kind of rationalization and control of human reproduction and that it encourages us to think of human nature in terms of a limitless self-modifying freedom. This is ethical reflection that does not pause immediately and constantly to worry whether a pluralistic society can digest such reasons and arguments; instead, it takes seriously the human goods and meaning involved in what we do or ponder doing. The same is true of Ramsey’s writing on other subjects–especially, the morality of war. To take just one example, to make one’s way through the essays on the morality of deterrence in “The Just War” is to be taught to think far more seriously than we generally do about missile defense as a moral issue. These essays are notoriously complex, as Ramsey refines his view and changes his mind several times. Indeed, Michael Walzer once wrote of Ramsey’s writings on deterrence that “he multiplies distinctions like a Ptolemaic astronomer with his epicycles.” We do Ramsey an injustice, however, if we overlook the fact that he wrote as a self-described “Christian ethicist.” Indeed, the two areas upon which he focused so much attention–warfare and medicine–are held together in the specifically theological language of one sentence in the preface to “The Patient as Person”: “Just as man is a sacredness in the social and political order, so he is a sacredness in the natural, biological order.” Sometimes Ramsey used the language of agape, Christian love, sometimes the language of covenant fidelity (which, while for him largely continuous with the language of agape, allowed Ramsey to make more immediate contact with the practice of medicine, which is itself covenantal). Nevertheless, the theological underpinnings of Ramsey’s reasoning are not always on display in his writings on warfare or medicine. In part, this was because he sometimes found non-theologians to be his most helpful interlocutors. Thus, for example, looking back on his work in medical ethics and his disagreements with Robert Morison (a scientist who did not share Ramsey’s theological commitments), he wrote: “I always learned more from Morison than from many a soft-headed theologian.” MORE IMPORTANT, however, Ramsey thought he had theological reason for beginning with what he could learn from those whose vocation it was to think and know much about the practices of warfare or medicine. That theological justification Ramsey found in the Christology of the first chapter of the Gospel of John, which describes the Word made flesh as One who comes to those who are “his own,” who cannot therefore be entirely alien. Of course, whatever one learns from those who practice medicine must still be brought within the scope of covenant fidelity and thereby transformed, but Ramsey was willing to begin that transforming process by gratefully accepting wisdom wherever he found it. Very early in his career, Ramsey had edited Jonathan Edwards’s “Freedom of the Will,” the first volume published in the Yale Press edition of the works of the great early American theologian and evangelist. That issue itself does not seem to have engaged Ramsey’s sustained attention, but Edwards clearly did. The years between Ramsey’s retirement in 1982 and his death in 1988 were largely devoted to editing another volume of the “Works,” “Edwards’ Ethical Writings.” Ramsey’s introduction to this volume runs to 121 pages, and earlier drafts of it were longer still. Clearly, he found in Edwards a depth and agility of mind, as well as theological insight, that he relished enormously. Ramsey’s very first book was “Basic Christian Ethics,” and it was never clear whether the later developments in his views were merely amplifications of that first book or whether his thought had turned in new directions, and Ramsey was often encouraged to write another “Basic Christian Ethics” at the end of his life. That idea he always resisted, but in some ways the engagement with Edwards–and the long introduction, which is, in many respects, not just about Edwards but about Ramsey thinking about and with Edwards–is a return to such systematic themes. Ramsey put his completed Edwards manuscript in the mail, knowing that he was scheduled to see his doctors, who might well have bad news for him (which, in the event, they did). One has to believe that the date at the end of his long introduction to the volume is done with great self-consciousness; Ramsey was not the kind of man to miss the significance of a gesture. The introduction is dated “Feast of St. Luke the Physician.” At his last class lecture prior to retiring, Ramsey had used the occasion to read to his students from Edwards’s “Charity Sermons.” The fifteenth and last of those sermons, which Ramsey greatly relished, is titled, “Heaven is a World of Love.” “All things in that world,” Edwards writes, “shall conspire to promote their love, and give advantage for mutual enjoyment. There shall be none there to tempt them to hatred, no busy adversary to make misrepresentations or create misunderstandings.” What, we might wonder, will there be for the intellectual street fighter to do? Edwards has the answer: “There shall be no want of strength or activity, nor any want of words to praise the object of their love….Love naturally desires to express itself; and in heaven the love of the saints shall be at liberty to express itself as it desires, either towards God or one another.” In short, an endless conversation, a heaven perfectly suited to Paul Ramsey. Gilbert Meilaender holds the Richard and Phyllis Duesenberg Chair in Christian Ethics at Valparaiso University.
