Introduction

It has been an honor and a privilege to co-edit this special issue of Theoretical Medicine and Bioethics in honor of Robert M. Veatch. I met Bob in 1991 when I participated in the Kennedy Institute of Ethics Summer Intensive 1-week course, and I left DC with a mentor for life. Over the next three decades, Bob was always available and was an incredible sounding board in virtually any area of bioethics that one could imagine. Over time, I went from student to colleague to collaborator. I am a lucky woman.

When Dan Sulmasy asked me to organize a festschrift to reflect upon Bob’s legacy, I knew I had to pay it forward, as there is no way I could ever give back the support and respect that Bob gave to so many. I thought it would be fun to take the journey with my former trainee, now colleague and collaborator, Jennifer Walter. I met Jen when she came to the University of Chicago to do her pediatric residency in 2007 having earned an MD and a PhD in philosophy as part of a joint degree program from Georgetown University. Back in 1982, when I matriculated into medical school, very few programs would consider accepting a student to do an MD/PhD in philosophy. It was so exciting to hear about Jen’s journey and her experiences at Georgetown, especially at the Kennedy Institute of Ethics where Bob was a teacher and mentor. All told, she spent a decade under the umbrella of so many of bioethics’ grandfathers.

We invited a diverse group of scholars to comment on Bob’s work, which is necessary since his breadth of knowledge and publications are unmatched. And we wanted scholars from all stages of Bob’s academic life. We are thrilled that several of his contemporaries and some of his mentees agreed to provide a personal anecdote as well as to reflect upon his work and his influence on the field of bioethics.

The first piece is by Tom Beauchamp, who reflects on Bob’s early days at the Hastings Center (originally the Institute of Society and the Life Sciences), Bob’s recruitment to Georgetown (where Tom was on faculty), and their co-editing of the second edition of the book entitled Ethical Issues in Death and Dying (1996) [1], the first edition having been edited by Tom with Seymour Perlin, MD (1st edition, 1978) [2]. Bob would take deeper dives into the concept of death and dying throughout his career [3,4,5]. Tom also offers us a glimpse of the Renaissance man that Bob was by describing his encyclopedic knowledge and love of Bluegrass music. For those who knew Bob personally, this essay will bring a smile; and for those who did not know Bob well, this piece gives you a glimpse of the founding (and founders) of our field.

The second piece is from another founder of bioethics, Jim Childress, who discusses Bob’s contribution to the field of deceased donor organ procurement and allocation, a field in which Jim has also been a seminal scholar and has served on many national committees. Jim offers a fundamental critique regarding the relationship of Bob’s ethical theory and public policy as it relates to organ procurement and allocation. Regarding deceased donor organ procurement, Jim examines Bob’s support for mandated choice as a reflection of his support for the primacy of autonomy despite the fact that it may lead to fewer organs being procured. Jim argues that Bob’s rejection of presumed consent may not only be inefficient but may also fail to “register what individuals want to happen with their organs after their deaths; they apparently often reflect their fears about what will happen to them if they are on record as organ donors” [6]. Jim also critiques Bob’s ideal theory of organ allocation because it gives lexical priority to egalitarian justice over medical utility in organ allocation. While Bob claims that there are limits on what should be given to the (Rawlsian) worst off, Jim argues that the lexical priority means that “‘no amount of medical utility’ justifies overriding the egalitarian claim of justice” [6]. Bob’s solution is to employ non-ideal theory in public policy, as seen in his paper “General Principles for Allocating Human Organs and Tissues” written when he served on the United Network for Organ Sharing (UNOS) Ethics Committee where he gives equal weight to medical utility and egalitarian theory [7]. Jim bemoans not being able to further discuss with Bob “his methodology for relating ideal theory to nonideal theory” [6].

Laura Guidry-Grimes, the most recent Kennedy Institute of Ethics graduate of our contributors and the most recent book collaborator with Bob, also describes a lack of closure regarding Bob’s views. Although she co-authored the 4th edition of The Basics of Bioethics [8], for the festschrift she has chosen to focus on one of his earliest books, The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality [9]. In her essay she notes that the book was distinctive in focusing on the needs and interests of persons with disabilities long before the rise of the field of bioethics called disability bioethics. Laura praises Bob for his argument that “we all have handicaps that would entitle us to compensation if only the resources were adequate. Since we are all in this situation, all are in one class. Everyone is handicapped; no one is part of the group we call ‘they,’ no one should be stigmatized” [9]. However, she notes that Bob views disability as a form of weakness, neediness, or lesser-than existence, and it is as “a result of ‘losing’ the natural lottery [that] society has an obligation to allocate resources to make up for these inherent disadvantages” [10]. Laura rejects the framing of disability as an inherent weakness and instead adopts Rosemarie Garland-Thomson’s disability lens which “frames disability as valued social diversity and supports the civil and human rights-based understanding of disability” [11]. Laura then shows why this framework better helps us understand what is owed to those who are disabled during the COVID-19 pandemic. She criticizes pandemic frameworks that incorporate a utilitarian calculus as discriminatory towards those with severe disabilities who are more likely to die even if maximally treated. She wonders what position Bob would take “since he argues in Foundations of Justice that additional resource allocations should be limited when doing so would jeopardize others’ well-being to the same degree” [10]. While she suggests that “Veatch would have supported recommendations to remove disability bias from triage criteria and decision-making processes,” regrettably it is a line of questioning she did not address before his death [10].

Laurence McCullough describes “Robert” (Larry’s preference) as one of his mentors during his post-doctoral fellowship (1975–1976) at the Hastings Center and then as a colleague at the Kennedy Institute before he moved to Texas and now New York. Another Bluegrass enthusiast, Larry provides a heart-warming description of Bob and Bob’s influence on him: “I learned from Veatch…by learning how and why I disagreed with him, which is the highest compliment that one philosopher can pay another” [12]. In this essay, Larry focuses on Bob’s less well-known book Disrupted Dialogue: Medical Ethics and the Collapse of Physician-Humanist Communication (1770–1980) (2004) [13]. In this book, Bob shows that doctors and humanists were in intense conversation between 1770 and 1800, but the narrowing of medical education led to a medical morality that was isolated from the wider culture which is only re-established in the 1960s. Larry, in contrast, offers a different origin story of eighteenth century medical ethics—one that arose “from a single discipline, Baconian science, not an interdisciplinary context” [12]. Larry argues that as physicians drifted away from Baconian science, they were left adrift. As Larry writes: “It should have come as no surprise that, when American physicians recognized in the 1950s and 1960s that they faced significant ethical challenges, they had to turn to intellectual resources outside of medicine” [12]. Either way, Bob’s role as a humanist in conversation with professionals across the health care spectrum helped restore a moral core to modern day medicine (and as the next contributor shows, to medical education as well).

Our next contributor, Amy Haddad, is trained as both a nurse and ethicist and she has co-authored with Bob three editions of Case Studies in Pharmacy Ethics [14,15,16], and two editions of Case Studies in Biomedical Ethics: Decision-Making, Principles and Cases [17, 18]. As both a collaborator and insider to Bob’s methods, she explains that he elected to use authentic clinical cases to engage students which he then used to expose them to “the rudiments of philosophical ethics so they could understand the conflicts between values, principles, and ethical theories” [19]. While he was not unique in the use of case studies, Amy points out that he was a pioneer in including all the health science disciplines–from nursing, dentistry, pharmacy, and allied health to medicine–and in the solicitation of cases from clinicians to make it authentic. Her essay sheds light on the critical role that Bob played in the re-integration of ethics into medical education for students, trainees, and practitioners at all stages of their career.

Anne Drapkin Lyerly, a researcher at the intersection of gender, reproduction, and ethics, was unaware of the Goldzieher study when we asked her to reflect upon Bob’s article about the study which he published 50 years ago (1971) in the first issue of The Hastings Center Report [20]. The Goldzieher study was a study designed to measure side effects of different contraceptives. It enrolled almost 400 women, mostly poor and Mexican–American, in a trial that included a placebo arm without the women’s consent and resulted in several pregnancies [20]. Annie praises Bob’s focus and critique on the pregnant woman as research participant in contrast with the many bioethics writings that focus on fetal risk: “’Experimental Pregnancy’ is worth revisiting—not just as a tribute to Bob Veatch’s legacy, but as a source of important lessons for how the research ethics community might better serve the interests of women and childbearing people” [21].

Christine Grady is the director of the NIH Department of Bioethics, the epicenter of research ethics. Like Annie, she finds Bob’s early writings on research ethics to be progressive for their time. She points to the Patient as Partner [22] in which Bob argued “that research patients should not be thought of as passive subjects nor material from which to obtain data, but rather as partners in discovery” [23]. As Christine explains: “Veatch’s proposal for a research partnership is based on the simple idea of treating the patient as a person and partner in research and what that implies for the ethics of clinical research” [23]. She examines how that idea has grown in acceptance and continues to evolve and face novel challenges given the changing landscape of research and the appropriateness of patient engagement and partnership in a range of research types.

Our final essay is from Eran Klein. Like Jen Walter, Eran earned his MD and PhD in philosophy from Georgetown. In his essay, he focuses on the “clinical relationship” (previously called the doctor-patient relationship). He begins with Bob’s “Models for Ethical Medicine in a Revolutionary Age” [24], in which Bob examines and rejects the engineering, priestly, and collegial, and instead proposes the contractual model of the doctor-patient relationship. The contractual model is a three-layer contract: The first layer focused on developing institutions that are akin to those developed in Rawls’ hypothetical contract in A Theory of Justice [25]; the second layer is focused on the physician as professional and the ground rules for the practice of medicine; and the third level is focused on individual doctors and patients who contract for the provision of health care in the clinical setting [26]. Eran points out that “not all interactions between patients and clinicians fit this paradigm neatly. Dementia is one such example” [26]. He then goes on to explore how dementia challenges the clinical relationship–both because dementia leads to changes of patient identity, and the role that it demands of families in the patient-clinician relationship. Eran argues that Bob’s individualistic conception of autonomy view deserves most of the blame, and Eran argues that relational autonomy is more suited for supporting all types of patients. He looks to the work of Hilde Lindemann who argues that families do “the work of preserving maintaining, and nurturing people” by telling and retelling stories about who the person with dementia is in order to hold them in personhood [27 at p. 422].

Like Eran, I have critiqued Bob’s understanding of the doctor-patient relationship. Where Eran explored Bob’s writing over many articles and books, I want to focus on a book that Eran does not discuss: Patient Heal Thyself: How the new medicine puts the patient in charge [28], which I reviewed for JAMA in 2009 [29]. In my review of the book, I wrote: “Robert Veatch describes the transition from medical paternalism to current-day modern medicine as a halfway transition from “physician knows best” to “patient empowerment” and “explores the next steps that will be required to fully empower patients” [29, p. 1388]. The book frustrated me because it assumed that patients wanted to have their (individual) autonomy maximized. However, as a primary care physician and patient advocate for family members and friends, I have learned that patients, particularly those who are seriously ill, often want empathy and support rather than authority. This is not to say that they want to be excluded from the decision-making process, but rather that it may be the wrong time to ask them to fully take on the task of ship captain. I thought that “many patients may not want the full burden of health care responsibility…but rather to collaborate with their physicians” [29] akin to Eran’s notion of relational autonomy. Bob expressed his frustration (disappointment?) that I misunderstood his work. I told him that I did not think I misunderstood his argument; that what he wrote fully expressed how he and I would want to be treated when we were seriously ill, but that we were the exceptions to the rule. I remember saying, “I’m sure there are at least a dozen or so folks like us, but I haven’t met them (yet).” I also confessed that I was not confident I would want this full authority when I inevitably face a serious health crisis. But Bob truly believed in this conception of the doctor-patient relationship.

As it turns out, a mere ten days before he died, Bob and I were still discussing nuances about defining death, the focus of our second co-authored book [5]. We were both invited to serve as observers to the Uniform Law Commission which was going to convene a Study Committee to examine whether to update the Uniform Determination of Death Act. Bob recused himself due to family caregiving responsibilities. As we strategized, Bob mentioned that he was not feeling well and that he was going to have some abdominal imaging done the following week and would then explore his options with his physicians. As I look back upon our conversation, I realize he was the captain of his ship, and he was saying goodbye to those of us on the shore.

Bob understood that the practice of medicine is a moral endeavor and through his writings and discussions, he has been an indefatigable moral compass for us all. May his memory be a blessing.