Nick Spencer reviews ‘Pain, Pleasure, and the Greater Good’ by Cathy Gere, a study of utilitarianism in public and medical ethics.

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In the summer of 1832, the inappropriately–named Angel Meadow, one of the ugliest slums of industrial Manchester, was hit by a cholera epidemic. Hundreds died, including a three year old boy who was being ‘treated’ at the Swan Street Cholera hospital.

At the funeral, the child’s grandfather, a Catholic called John Hayes, noticed that there was no name chalked on the coffin lid. Suspecting that something had happened to the body, he climbed into the grave and tried to force the lid off. When he finally got it open, with the help of the sexton, he found the child’s body intact but its head replaced with a brick wrapped in shavings.

Hayes went to get help, a furious crowd gathered, and body and brick were seized and paraded through the streets of Manchester until the crowd reached the hospital, which they proceeded to trash and burn until the troops were called. The priest from whom Hayes had first sought help managed to find the child’s head and a surgeon to reattach it. A few days later, the local Board of Health was convened, blamed the incident on a Mr Oldham, the recently appointed hospital apothecary, who had long since fled, and, to calm the still–raging family and crowd, arranged for the priest to rebury the body in a lead casket on Catholic burial grounds.

The tale of the Swan Street riot may at first seem like a straightforward, gothic tale of mutilation and mob rule but it is, in fact, more interesting and more instructive.

Disconcertingly, the actions of Mr Oldham and the Swan Street Hospital were not maverick or even illegal. They were more or less within the realms of what was judged morally and legally permissible according to the emerging ethos and laws of industrial Britain.

Earlier that year – indeed on the same day that it passed the Great Reform Act – Parliament had passed the Anatomy Act, which made the bodies of people too poor to pay for their own funerals available to medical schools for dissection. It did so on the basis of a moral ideology that was in the ascendancy.

Physicians saved lives – or at least they would do if they knew how to. But knowing how to, involved understanding the human body and that necessitated human dissection. Experimentation on living humans was, of course, forbidden (we had to wait until the 20th century for regimes to permit that), but the law had recently been relaxed to allow the use of corpses, particularly poor ones.

The logic for this was clear. “Nature has place mankind under the governance of two sovereign masters, pain and pleasure” wrote Jeremy Bentham at the start of his 1789 Introduction to the Principles of Morals and Legislation. “The business of government,” he continued, “is to promote the happiness of a society, by punishing and rewarding.” So it was that decapitating a dead child caused the child no pain and its relatives no concern (as long as they remained unaware) but could advance this business of government by enabling medics to understand, relieve, and even abolish, pain in the future. In the calculations of the greatest good, the non–suffering of a dead child weighed precisely nothing.

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Our revulsion at this story is testimony to the power of our moral convictions working at a subconscious level. We know Mr Oldham’s actions were wrong because we feel they were wrong.

There is, however, a danger in this (beyond the familiar one of needing to use your brain and not just your guts to evaluate morals). The strength of our intuitive response leads us to denounce Mr Oldham, and his ilk, as monsters: ‘unthinking’, ‘unfeeling’, ‘immoral’, and so forth.

But they were not. They thought they were doing good. Indeed, they calculated that they were doing good. As Cathy Gere puts it in Pain, Pleasure, and the Greater Good: From the Panopticon to the Skinner Box and Beyond (2017), her absorbing study of utilitarianism in public and medical ethics, “human experimentation was not a battle between good and evil, but rather a conflict between two conceptions of the good.”

The “human experimentation” she mentions here was live human experimentation, specifically the notorious Tuskegee experiments in which hundreds of black man in Alabama were (unknowingly) denied treatment for syphilis as part of a decades long experiment to explore the progress of the disease. The men were poor, lied to (they were told they were getting free treatment, and later denied the penicillin that would have cured them), and many were subject to extremely painful treatments, such as spinal taps (a grim procedure indeed in the 1930s). The affair only emerged in the 1970s, many years after trials at Nuremberg had established that informed consent should be the keystone of all medical experimentation.

The doctors involved in Tuskagee, especially those who justified what they were doing in the subsequent hearings, were savaged in the press but, as Gere is at pains to emphasise, they were guided by their own, coherent moral logic.

“Time and again, nonconsensual research on terminally ill, marginal, impoverished, incapacitated, undereducated, or institutionalised human subjects was rationalised on cost–benefit grounds: terminal patients would die soon anyway; poor rural populations were otherwise out of reach of medical care; illiterate people could not be expected to understand risk; state asylums were already rife with communicable diseases; the lives of institutionalised people with disabilities were so unpleasant that research procedures represented little extra burden.”

And – above all – the results of these human experiments would, in the long run, be of measurable utility, reducing the sum of pain in the world and adding to the sum of pleasure.

Gere’s book traces the road to Tuskagee, maintaining a particular focus on medical ethics. As Gere says:

“the medical sciences owe much of their success to a mechanistic understanding of our biology, including how our bodies and brains produce our desires and decisions. The scientific focus on right chains of cause and effect has no place for genuine freedom of action. So much for the ‘autonomous self’ that should undergird the practice of informed consent. The ‘utilitarian self’, by contrast, is a perfect fit with medical science.”

Nevertheless, she wonders through broader fields of public ethics, usually in Bentham’s footsteps, and what she says has a relevance much wider than medical ethics committee debates.

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Gere begins with Tuskegee before stepping back a generation to the arguments of the Nuremberg trials. During these, the prosecutors had appealed to the universal principle – and lack – of informed consent as a major charge against Nazi doctors, only to realise that not only was the principle not universal but (a) that it was, ironically, “quintessentially German, springing from a concept of transcendent human dignity found in the moral philosophy of Immanuel Kant” and, worse, (b) that had been consistently flouted among the Allied nations, the defence submitting a document “detailing research conducted in Allied countries, involving a total of approximately 11,000 subjects”. This was too close for comfort, not least for a nation determined to hold on to the moral high ground in the chilling Cold War, and the full implications of informed consent, and the West’s only partial adherence to it, had to wait decades to emerge.

Thereafter, Gere goes back several centuries to explain how utilitarianism gained its grip. Beginning with the re–appropriation of Epicurus in the 17th century and the “reduction of human reason to a bestial succession of appetites and aversions”, chapter 2 is a breakneck tour or proto–utilitarian thinkers – Hobbes, Locke, Frances Hutcheson, Claude Helvétius, Adam Smith, David Hartley – arriving finally, inevitably, at the towering, eccentric and unlovable figure of Jeremy Bentham.

Bentham’s obsessively systematising mind sought a clarity in the calculus of utility that was at first unpopular, but which became more palatable in intellectual chaos of the 1790s, as French revolutionaries disgraced the notion of natural rights. His new world was framed in new words and phrases (he invented maximise, minimise, rationale, demoralise, deontology, disambiguation, dynamic, international, unilateral, exhaustive, self–regarding, cross–examination, sexual desire, false consciousness and, of course, utilitarian, among many others that didn’t catch on) as he resolutely eroded the significance of intentionality, conscience, and all inner states. “In pairing murder with farming and rape with marital sex,” Gere says, having quoted him doing just that, Bentham “exposed the vein of moral nihilism in utilitarianism that would agitate its critics from his day to ours.”

Be that as it may, and in spite of his failure to get his beloved Panopticon prison funded by the government, Bentham, accompanied by fellow travels like the devout (Christian and utilitarian) Thomas Malthus, articulated a view of human nature that shaped medical and public policy in early industrial Britain, such as through the Anatomy Act mentioned above and through the New Poor Laws. “The workhouse inmate” was a utilitarian creature, “its body” – and Gere’s use of ‘its’ here is spot on – “was Malthusian: a bare, forked creature, hovering on the brink between procreative life and premature death, threatening to breed, competing for scarce resources. Its nervous system was Benthamite: an animal bundles of appetites and aversion completely controllable by rewards and punishment.” The consequences can be read in Oliver Twist.

Utilitarianism became more ‘scientific’ as the 19th century progressed, Alexander Bain, David Ferrier and others making “behaviourist psychology” ever more robust and credible, albeit at the cost of lives, such as that of 30–year–old Mary Refferty, a poor Irish housemaid who presented herself at hospital for a severe ulcer on her scalp who was experimented on and (inadvertently) killed by the American Roberts Bartholow. By the early 20th century American researchers had taken the lead and “‘behaviourist psychology’ became the bastion of antihumanism at the centre of the human sciences.” Proposing reductive explanations for human action “became a badge of scientific toughness”, with few tougher, or more influential than B.F. Skinner for whom trainable rats were an acceptably and sufficiently accurate model for human beings.

Things changed (slowly) in the post–war period. The world became cognisant of the horror of Nazi experimentation. The politics of the Cold War underlined that if America stood for anything it stood for the freedom to which utilitarianism and behaviourist psychology were indifferent. Naom Chomsky demolished of B.F. Skinner’s work in reviews and books that were unhampered by academic politeness. A spectacularly ill–timed behaviourist intervention by Sandor Rado proved how homosexuality could be cured by basic utilitarian system of stimulus and rewards. Rights, a bête noire of utilitarians from the 1790s, triumphed in public and political discourse. By the 1970s, after the Tuskagee trials, “the ranking of the principles [in medical ethics was] firmly established. Autonomy rules in contemporary research ethics and clinical practice, but utilitarianism, in the guise of ‘beneficence’, happily co–exists with it as a close runner up.” The reign of utilitarian ethics in medicine and political was over.

Or perhaps not: Gere ends her book with a chapter which shows that in spite of all this, for some well–recognised reasons (such as the rise of behavioural economics and rational–choice theory) and for some less well recognised and counter–intuitive ones (such as the demand for AIDS treatment to be available long before the time demanded by clinical trials) utilitarian ethics is creeping back.

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Gere’s study of the path of utilitarianism in modern public and medical ethics is a model of readable, reasonable intellectual history. It is also heartfelt, perhaps because Gere herself admits, in her Introduction, that as a student she fell under the spell of R.M. Hare’s utilitarian ethics and only grew out of it later. There is a touch of the lover deceived in her history.

But the story also points to a bigger question, which may explain why I have reviewed it at such length.

All too often public debate today, even in a self–consciously plural and ‘diverse’ society such as our own, defaults to certain unexamined norms and then treats other approaches as anomalous, too be tolerated (most of the time); to be banned (if deemed harmful). This is increasingly the case with regard to Christianity, the orthodox Christian views on abortion, sexual behaviour, and euthanasia, for example, seeming aberrant. (Equally orthodox Christian views on human equality, the demands of peace, the stewardship of creation, and the imperative of tackling ill–health, ignorance and poverty are still part of the unexamined norm, and so not treated with such suspicion. The significance of religious freedom, another orthodox position, hovers somewhere between the two.)

Yet, as Gere emphasises, and to return to an earlier quote, only in the minds of the morally simple does the world satisfactorily separate into goodies and baddies. Most of the time, it’s a question of different people pursuing different conceptions of the good, some of which happen to look abhorrent from the standpoint of other goods.

So it is in this story. Many of the utilitarian examples revealed in her book strike this reviewer (and I daresay most readers) as morally grotesque, but by their own Benthamite or Skinnerian logic of the good, they work. In other words, I say they are wrong because, according to where I am standing from, they are wrong, not because I know, from the vantage point of complete impartial objectivity, that they are wrong.

This worries many people, not least Christians, as they see it as the first giant leap towards moral relativism: I can’t know you’re wrong; I can only say that from where I am standing, you are wrong. This, however, I would contend is, in fact, not only more honest, but also more liberating. We live in contested moral space and it is up to everyone, not just those who find themselves standing outside the mainstream to justify their views on the good. ‘Why do you believe what you believe about the good?’ is a question that should simultaneously open up and level the playing field of ethical public discourse – not least because the question of the good almost inevitably get passed on up to a higher court which asks the same thing of our conception of the human.

Gere spent some time in her first academic teaching job attending weekly meetings of the ethics consulting team at the University Hospital in Chicago, immersing herself in the medical ethical universe about which she writes in this book. “As I listened to the deliberations of the ethics team at the University of Chicago Hospital,” she explains, “it struck me that the issues dividing the assembled doctors were as much about human nature as about moral principle… one weary veteran described these views as ‘competing and incompatible conceptions of the self.’”

This is the end point – or better still the last arena – for our debates about the good. The good for whom? What is this animal/ hominid/ human/ person (no word is neutral) whose good we seek? This question is answered by Jeremy Bentham in one way, by Immanuel Kant in another, by Ayn Rand in a third, by Karl Marx in a fourth, and so on.

It is also answered by Christian thought, reflecting the life, teaching, sacrifice, death, and resurrection of Jesus Christ, the answer(s) debated, elaborated and clarified, and the implications expanded and elucidated, by the enterprise of theological reflection. It is an enterprise to which we at Theos hope to make a contribution, and a debate, which Gere’s fine book reminds us, is long–standing, ever–present, and very important.