History
Taking a wider view of the patterns of provision, it is clear that the relocation of middle-class patients requiring institutional care, from the nursing home to the hospital, was only partially achieved over the early twentieth century. The specialist services of Bristol's hospitals, particularly in maternity care, contributed to a dual hub split between the two cities, jointly providing hospital services to the region's middle classes. This variation in locality, size and type of hospital both explains the atypicality of Bristol and nuances the 'insufficiency' of private provision identified by Bridgen. Understanding the type of hospital (i.e. general or specialist) can help us gain some understanding of what kinds of medical treatment were being provided to middle-class patients. Placing our focus on the idea and the act of payment both heightens and diminishes the significance of 1948 as a watershed in the history of British healthcare.
This book examines the payment systems operating in British hospitals before the National Health Service (NHS). An overview of the British situation is given, locating the hospitals within both the domestic social and political context, before taking a wider international view. The book sets up the city of Bristol as a case study to explore the operation and meaning of hospital payments on the ground. The foundation of Bristol's historic wealth, and consequent philanthropic dynamism, was trade. The historic prominence of philanthropic associations in Bristol was acknowledged in a Ministry of Health report on the city in the 1930s. The distinctions in payment served to reinforce the differential class relations at the core of philanthropy. The act of payment heightens and diminishes the significance of 1948 as a watershed in the history of British healthcare. The book places the hospitals firmly within the local networks of care, charity and public services, shaped by the economics and politics of a wealthy southern city. It reflects the distinction drawn between and separation of working-class and middle-class patients as a defining characteristic of the system that emerged over the early twentieth century. The rhetorical and political strategies adopted by advocates of private provision were based on the premise that middle-class patients needed to be brought in to a revised notion of the sick poor. The book examines why the voluntary sector and wider mixed economies of healthcare, welfare and public services should be so well developed in Bristol.
This chapter seeks to answer whether the incorporation of payment into the working-class patient contract amounted to an abandonment of philanthropy. The appointment of hospital almoners to conduct what was effectively a means-test served as a double-safeguard. First, it allowed the hospital to grant reductions and exemptions to those unable to pay, ensuring this did not become a barrier to access. Second, along with the setting of income limits, the assessment of the almoner was a mechanism for weeding out those of the middle and upper classes who were not considered appropriate cases for medical charity. Prior to the First World War, Bristol's voluntary hospitals were typical in operating two well-established systems for admission: subscriber's tickets and 'receiving day'. More fundamentally, admission was not conditional on either almoner-assessed payment or contributory scheme membership.
This chapter surveys some key themes in the historiography of healthcare in early twentieth-century Britain and presents a few enlightening international comparisons. A more nuanced understanding of the place of payment in British hospitals before and after 1948 adds to a growing appreciation that it was the high-point in a longer period of kaleidoscopic change. The history of the voluntary hospital system is itself, inevitably, bound up with funding. The question of whether a hospital could remain a charity whilst taking payments from patients, the recipients of that charity, is hard to separate from a wider historiographical debate in the social histories of medicine in Britain, Europe and North America, on whether the hospital had by now lost its social function. The pre-National Health Service (NHS) citizen patient was not so much a citizen-consumer or a welfare citizen as a citizen-contributor.
Many of the academics who taught on new interdisciplinary ethics courses were increasingly located in dedicated bioethics centres from the late 1980s onwards. During the 1960s and 1970s, as Edward Shotter notes, 'there was no teaching in ethics in British medical education' and leading doctors believed that ethical questions were best 'discussed by consultants, with consultants and in camera'. The non-doctors who taught medical students were initially based in law, philosophy and social science departments. The pressure on philosophy departments was compounded when the government replaced the University Grants Committee (UGC) with a new Universities Funding Council (UFC) in 1988. The degree's structure and focus, with input from many staff and departments across the university, reflected the British attitude that no one profession should dominate medical ethics or bioethics.
Mary Warnock's support for assisted dying is significant in a number of respects. It shows, first, how an individual's ethical views are not fixed and can change according to what the observer called 'the lessons of life'. Secondly, and more importantly, it shows just how much authority bioethicists are thought to wield over public affairs. The fact that a philosopher fronted an episode of the BBC's flagship science series again shows how bioethicists emerged as a 'new epistemic power' in Britain from the 1980s onwards. Although the notion of moral expertise remains contested and many bioethicists refuse to acknowledge it, they are often portrayed as what the Guardian called 'ethics experts'. The legal philosopher Gerald Dworkin, working at Queen Mary University in London, highlighted the major differences in his paper on the 'delicate balance' between ethics, law and medicine in Britain and the United States.
During the 1980s, many of the individuals who were pivotal to the making of British bioethics sought to establish what the British Medical Journal identified as a 'national bioethics committee'. Ian Kennedy was the strongest advocate of bioethics in Britain during the late 1970s and early 1980s, so it is no surprise to find that he was also the first individual to endorse a national bioethics committee. Sir David Weatherhall's lobbying led members of the Nuffield Foundation to undertake informal soundings on the need for a national bioethics committee. After Foundation trustees approved the steering group's terms of reference, the Nuffield Council on Bioethics was officially established in May 1991. The Nuffield Council's limited impact on policymaking ensured that bioethicists continued to have greater authority as members of ad hoc public inquiries.
Doctors and scientists successfully argued that they should be left to determine their own conduct during the nineteenth and much of the twentieth centuries, in a form of self-governance that Michael Moran terms 'club regulation'. They portrayed medical and scientific ethics as internal concerns in this period, produced 'by and for' colleagues and mainly concerned with limiting intra-professional conflicts. The emergence of club regulation in medicine and other professions resulted from social and economic changes during the nineteenth century. The reluctance to issue binding ethical guidelines was mirrored by the British Medical Association (BMA), which represented the interests of doctors after its formation in 1836. The BMA's belief that collaboration with theologians was 'necessary and desirable' might appear surprising, as club regulation was particularly strong in the late 1940s.
During the 1960s and 1970s Anglican theologians increasingly endorsed 'trans-disciplinary' discussion of new procedures such as in vitro fertilisation (IVF) in societies and journals dedicated to medical ethics. Figures such as Ian Ramsey, an Oxford theologian and later Bishop of Durham, endorsed greater engagement with social and moral issues to maintain the Church's relevance in the face of increasing secularisation. He viewed theologians as the 'common link' who facilitated debates between 'experts in different disciplines and from different occupations'. This was especially the case for discussions of medical and biological research, which Ramsey considered to be the major source of 'frontier problems' in the 1960s and 1970s. Joseph Fletcher, professor of Christian ethics at the Episcopal Theological School in Cambridge, Massachusetts, was one of first American theologians to look at scientific and medical ethics.
This introduction presents an overview of the key concepts discussed in the subsequent chapters of this book. The book explores how and why bioethics became so influential in Britain, including the archives of government departments, public inquiries, universities and professional organisations, as well as private papers, published materials, press reports, television programmes and interviews. It looks at why doctors and scientists came to regulate themselves throughout the nineteenth and for much of the twentieth century. The book examines why outsiders increasingly joined debates on medical procedures such as in vitro fertilisation (IVF) during the late 1960s and 1970s, and shows how this was led by Anglican theologians. It also examines the growth of bioethics in British universities during the 1980s and 1990s. The book also explores how some senior doctors and bioethicists led calls for a politically funded national bioethics committee during the 1980s.