 All right, my introduction to the next speaker can be very brief. It's me. In the summer of 1848, a young medical doctor and civil servant named Rudolf Fierkau wrote in the editorial column of a journal he had just founded called Medical Reform, some words that were to become famous. Let's see, hang on. The reform of medicine is necessitated not for the sake of the doctors, but for that of the sick. Doctors are the natural attorneys of the poor, the Naturlichen Anvelte der Armen, and the social question falls to a significant degree within their jurisdiction. I'm sure you've heard these words before. They're often cited in writings on public health, a discipline of which Fierkau has a claim to be one of the founders. And they have been identified with a position that is sometimes called physician activism or social advocacy, as distinguished from the attitude that says that physicians treat the patient's body and leave the rest up to professionals in law, economics, political science, theology, and so forth. The position Fierkau expresses here is so uncontroversial, in fact, that I feel it may be useful to reach back into the history of medical ethics and show in what ways it breaks with not only longstanding tradition, but with whole ways of framing the business of ethics. Now, it wouldn't be unreasonable to suppose that ethics consists of a general theory or set of principles about what justice or good action consists in, and then a set of local applications. There would be ethical theory, ethics per se, and then applied versions with their local characteristics, medical ethics, legal ethics, ethics for park rangers, museum curators, teachers, dog walkers, translators, taxidermists, conference moderators, and so on. Wherever you have people acting on behalf of other people, the classic questions come up. What is the nature of the caretaker's responsibility? How do personal interest and general interest interact? How do we formulate a criterion of justice? What is the order of priorities among the aims to be served? And presumably, it is general ethics that would outline the answers to these questions. And below that level, people cognizant of particular fields would tailor them according to their several necessities. But when you reach back into the history of ethical thought in the West, just to restrict our focus to that set of cultures for today, the story is rather more complicated and doesn't confirm this idea of a steady straight line progression from general rules to particular applications. As we like to do here at the University of Chicago, I will call Plato as my witness. In the Republic, we overhear Socrates and the gang discussing at great length the definition of justice. You have to have an understanding of justice before you can design the ideal state, the Republic of that dialogue's title. One of the speakers in the conversation, Pauli Marcus, holds to an old-fashioned idea of fair dealing, that the meaning of justice is to benefit one's friends and harm one's enemies. This is not good enough, answers Socrates. To benefit one's friends is well and good, but no one is truly just who chooses to harm others, even enemies. That is rather the behavior of the unjust person. For it has been made clear to us, says Socrates, summarizing the earlier discussion, that in no case is it just to harm anyone. Citizens owe each other at least the minimal consideration of not doing harm. That, for Socrates, is a step in the right direction, though it's hardly the end of the search. And suddenly, hold on, let me find the right bit here. Yeah, suddenly Thrasymachus bursts in. And, wait, hold on, I've got the slides all sideways here. Well, let me tell you what Thrasymachus says. Thrasymachus couldn't any longer hold his peace, but gathering himself up like a wild beast, hurled himself upon us as if he would tear us to bits. Says Socrates. Thrasymachus said, what balderdash is this that you have been talking, and why do you simple simons chuckle and give way to one another? Harken in here then. I affirm that the just is nothing else than the advantage of the stronger. Socrates then goes to work on Thrasymachus. He makes him first admit that sometimes the strong act against their own better judgment and make mistakes, which result in injustice being done even to themselves. Thus, there must be some kind of art of ruling, an art in which some are more skilled than others, and those skilled in this art might be the just. And is it not also true, says Socrates, that any art exists to discover and provide some advantage? Just as if you should ask me whether it is enough for the body to be the body, or whether it stands in need of something else. I would reply, by all means it stands in need. That is the reason why the art of medicine has now been invented, because the body is defective and such defect is unsatisfactory. To provide for this then is what is advantageous, that is the end for which the art was devised. Thus Socrates injects into the discussion the idea of a beneficent use of power, for which medicine is his example. Thrasymachus a little hastily accepts this idea, presumably because it does give advantage and power to the stronger party as his definition of justice had demanded. And an art like medicine is something strong. It is a technique that gives its practitioners enhanced abilities. But it should exercise those abilities for the sake not of the strong, but of the weak, that is for the sake of those who are benefited by it. There's a difference between the competence of an art and the domain on which it is practiced. For medicine that domain would be the defective human body. For public health it would be the public envisioned as an aggregate of such bodies. So there's a discussion then between Socrates and Thrasymachus about this. Can we deny then, says Socrates, that as a physician, physicians seek the advantage of the patient, right? Socrates could anticipate that there would be MDs with MBAs, but he says that when you're wearing your MBA hat, you're not wearing your physician's hat. Thrasymachus is not going to have any of this. He says, you think the shepherds and the neat herds are considering the good of the sheep and cattle and fatten and tend them with anything else in view than the good of their masters and themselves, right? That's going to be his metaphor for the state. Now in Plato, medicine was one of the analogies that allows Socrates to get a tighter grasp on what justice is. Justice will be the exertion by the stronger of an art that benefits those who submit to it, including the weaker. In the state, justice is the employment of the techniques of politics, lawmaking, and publicity for the benefit of the public which is ruled. Thrasymachus, who doesn't concede that there can be moral constraints on power, now has to backtrack. He has to throw out the idea of any art or technique and come back to the sheer power discrepancy and non-community of interests between sheep and shepherd that define his picture of the justice of the stronger. He knows what it means to act on behalf of the sheep and the cattle. It is to keep them in good enough condition to serve the purposes of the owners until it's time to turn them into good, healthy meat. Here, at least, there's no ethical ambiguity about who is serving who's interest. This discussion contains the kink that I was speaking of. When Socrates wants to understand what justice is, he resorts to a metaphor. As the doctor is to the patient, so the lawgiver is to the city. We can understand justice by thinking through the steps of medical treatment. But once the definition of justice has been established, Socrates and his interlocutors have no trouble using that definition to regulate medicine itself and prescribe to medicine certain tasks for the benefit of the community as they see it. In the later books of the Republic, we hear that medicine must be regulated by philosophers. It is the philosophers, the specialists in the good of the city who decide which citizens are deserving of medical care and which ones should be left to die without it. Once medicine has served Socrates to legitimate the discipline whose concern is justice in the state, it becomes, quite obviously, a mere instrument of state purposes including a form of eugenics. That's in Republic 407 and 408 if you're following along with your pocket play-toe. This metaphorical double dipping is a symptom of the difficulty in scaling up and down in thinking about medical care. I know, of course, that there are practical difficulties in scaling the treatments that we devise in our labs or in double-blind tests so as to make them available to populations that may be divided, populations that are non-homogeneous in all kinds of ways. Here we're dealing with a different dimension of scale, a semantic dimension. In the earlier passage of the Republic, Socrates is not concerned by the fact that the provision of medicine is something that states actually do regulate, distribute, and command in various ways. In a later passage of the Republic, medicine is merely the means for the state to maintain its strength through eugenics. It seems that once medicine has handed over its law-like properties over to the philosopher kings, it becomes yet another thing to be administered by them. Now let's go back to the Fairchild passage and consider it in this light. Fairchild's analogy of doctors with lawyer advocates goes in the other direction. Here, too, there is a relation between medicine and justice, but it begins with the patients. It begins with their need for care and it calls the state to account. It would not be enough to say that medicine is a metaphor in the Republic and a literal thing in Fairchild's 1848 editorial. The difference is rather in the way the term medicine serves as test and trigger of other concepts. So medical ethics is not just a domain of application of ethics per se. Medicine, in some way, founds the category of politics. It is as if we can't think about social organization without also thinking about medicine. And this is reasonable, because human beings are physical people, defective bodies, as Socrates recognized, and we need to be maintained in health, fed, kept in a suitable environment, or none of our speculations about justice will come to anything. A medical metaphor is also one of the argumentative resources of the version of libertarianism framed in Wilhelm von Humboldt's On the Limits of State Action, an essay from the exciting year of 1792. Humboldt had spent those years in Paris and was watching the transfer of responsibilities from the royal government to the revolutionary government in France. Humboldt starts from a broad humanistic claim that the true end of man is the highest and most harmonious development of his powers to a complete and consistent whole. So anything the state does will be subordinate to that imperative. You must develop man. The only job of the state is to stay out of the way and occasionally to serve as a referee invited to keep us from trampling on one another's rights. It does not itself create or confer any rights. And Humboldt is dismissive of the entire efforts of the state to elevate the welfare of the nation, as you can see in this couple of quotations. Humboldt elaborates on the well-intentioned damage that he thinks public benevolence will always inflict. He says states like those to which we refer, too often resemble the physician who only retards the death of his patient in nourishing his disease. Before there were physicians, only health and death were known. So to follow the steps of Humboldt's analogy, the state is a physician, but physicians are bunglers. Away with them then, let us live in the clear, stark alternative of health and death. As long as we're not dead, we must be healthy, right? This style of thinking relishes absolutes and subscribes to a magical idea that if the troublesome in-between of sickness and therapy is removed, what Socrates referred to as the defective body, then all those who are not dead will automatically be healthy. The doctor, for Humboldt, is the natural attorney not of the poor, but of poverty and sickness themselves. So the difference with Fairchild, I think should be pretty clear. And they're both, of course, living in Prussia, overlapping by a few years in their careers. Though Humboldt was a diplomat in Fairchild, of course, was a medical doctor. With Fairchild, the medicine to justice, relation is not to be put aside once it is served to point us on the road to justice. Medicine serves as the criterion for political legitimacy and that goes all the way up the logical chain. There is no point at which for him, politics takes over as an art distinct from healing. Fairchild's government on the Prussian government of his time, which he came to after observing cholera epidemic in Upper Silesia, was surprisingly harsh. You've seen this. After at the conclusion of his report on this cholera epidemic, Fairchild says, when the state, for any reasons whatsoever, whether these stem from heaven or from everyday life, allows its citizens to lapse into conditions in which they must starve to death, it ceases legally to be a state. Now that last sentence is an extraordinary thing to say in the Prussia of the 1840s. You might remember Hegel, who just a few years before had practically deified the state, saying that the state is the march of God through the world and nobody has a right to question the state and its purposes. Fairchild says that it doesn't matter whether the emergency in question comes from the heavens or from human action. It is an existential problem for a democratic state, which Fairchild defines as one desiring the welfare of all citizens since it acknowledges the equal rights of all. And he calls this the solidarity of obligation. In a way, Fairchild is doubling back on Socrates' use of medicine as the analogy of justice. Actual medicine, not just the concept of medicine, becomes the test of justice. And that, I think, is how it ought to be. Thank you.