It is with great pleasure that the Association of Bioethics and Medical Humanities (ABMH) announces the recipient of its first Lifetime Achievement Award. The Lifetime Achievement Award is given for a lifetime of academic accomplishment and community service in bioethics or the medical humanities. It is thus fitting that this year's award goes to the founding president of the AMBH, Ignatius Crawford Jr. of the Medical University of Saint Lucia. As the cultural anthropologist Clifford Geertz has pointed out, relationships between scholars are "typically not merely intellectual but political, moral, and broadly personal," because "having known each other too long and too well, they are characters in one another's biographies. Ignatius Crawford Jr. has been both a witness to the making of bioethics and a central figure in the lives of those who have made it. To trace out Professor Crawford's life is to trace the history of the modern bioethics movement.
Like many of his students, we have always been saddened that "the ethicist" (as his students referred to him) rarely published his extensive writings in academic journals. For some twenty years it has been rumored that Crawford is preparing a foundational text in bioethics, but ever fearful of misinterpretation, Crawford has guarded his manuscript carefully. Indeed, those of us who have drawn on Crawford's work have been forced to rely on the pirated copies of his lectures that have circulated informally among his former students and colleagues. It was not until his unexpected hospitalization in July that Crawford's daughter discovered his handwritten drafts of that text hidden in a shoebox under his bed. According to Crawford's earliest notes, the text was originally intended as a grand (some would say audacious) experiment in the metaphysics of morals: the development of a comprehensive bioethical theory combining the principles of Euclidean geometry, Presbyterianism, and match-up zone defense. However, subsequent years saw Crawford's manuscript revised substantially in response to intellectual currents. During the 1970s Crawford gave the manuscript the working title of Mega Principles: Your Guide to Bioethics in the 21st Century and Beyond, but he later changed it to I'm Virtuous, You're Virtuous, then The One Minute Caring, then Casuistry According to Winnie the Pooh, and finally The Complete Idiot's Guide to Narrative Ethics. But we get ahead of ourselves. Let us begin at the beginning.
Crawford was born in Nuremberg during the Nazi war trials. His father, Ignatius von Crawford Sr. was apparently a key figure in the trials, although it is unclear whether he was a defendant or a prosecutor or a building superintendent (although some have speculated that he was during different times all three, the order of which, however, is still a mystery). In any case, Crawford often recounted that his earliest memories were playing in the courtroom. By the time he was in his late teens he had already received two PhD's in philosophy (the first one in phenomenology for some reason did not take), a JD, an STD (gonorrhea), an MA in sociology (thesis: "Social Rituals and Customs of the Homeless Urban Academic from 1953-1959"), and a diploma in cosmetology. A revised version of Crawford's second PhD dissertation, in which he attempted to establish a historical connection between dietary habits and the capacity for abstract thought, was later published under the title Great Philosophers and Their Food (Mannheim Freie Presse, 1968). The book received poor critical notices, especially from some scholars in theAmerican South, in part because of Crawford's controversial claim that Kant had refused to eat fried okra on the grounds that it interfered with his concentration.
Crawford got his start in academic medicine with his ethnography of medical education, Among the Savages: An Insider's Account of Medical Education at Harvard University, which Crawford wrote while a visiting scholar at Harvard. It was largely on the basis of this seminal text that Crawford was appointed Chairman and sole member of the Department of Human Ethics at Duke University. At Duke, in response to widespread concerns that the process of medical training was producing hardened, disillusioned, cynical physicians, Crawford introduced a novel "health values" curriculum to humanize medical students, consisting of role playing, finger puppetry and interpretive dance. This educational experiment came to an ugly end when Crawford was the victim of a failed assassination attempt by a disgruntled second-year student wielding an automatic weapon and a finger puppet labelled "Mrs. Incontinence." At one point the student apparently told Crawford that he had to select members of the Department of Pathology to be killed or he himself would be killed. Bloodshed was narrowly averted when the student fell asleep during Crawford's lengthy discussion on the moral dimensions of this dilemma. Crawford was later given a cross-appointment in the Department of Anesthesiology.
Crawford went on to earn a reputation as a devoted but eccentric teacher at a number of different universities. According to his graduate students in philosophy at Cambridge, he insisted on delivering his lectures on metaphysics at home in his attic while lying supine on the floor. Fourth-year clerks in cardiovascular surgery at the Medical University of South Carolina swore that he insisted on being addressed as "The Great and Powerful Ignatius," and that he lectured from behind a curtain while projecting a giant image of his head onto a movie screen. However, it was Crawford's weekly "ethics rounds" in the MUSC Intensive Care Unit that were dreaded most by third-year students, mainly because of Crawford's notorious Socratic question-and-answer sessions, the results of which determined their entire grades in internal medicine. During these sessions Crawford developed his famous "reverse double-Jeopardy pimp", in which he would bark out an answer to an ethical problem, then point to a medical student who was expected to supply the question.
In the early seventies, Crawford was a visiting lecturer at the University of Washington's Sociology of Knowledge Department when one of his graduate students became quite ill while doing research on the effects of drinking bourbon on reading philosophy (Crawford had a theory that Wittgenstein could only be understood while drunk), for each morning the student was taking extraordinarily large doses of aspirin to deal with the hangovers. The students, whose kidneys had become quite useless, was under the care of Dr. Belding Scribner, who had just developed a permanent indwelling shunt which allowed patients to undergo dialysis. Crawford encouraged Scribner to perform his research on this ill graduate student (later he offered Scribner as many graduate students as he wanted), which resulted in his appointment to the hospital selection committee which decided who should and should not receive dialysis. Crawford proposed a number of controversial criteria for rejecting candidates for dialysis, including a series of complex distinctions between "socially useful," "socially neutral," "socially useless," "useful only as a dean," and "useless to anyone, anywhere, and at anytime."
It was at roughly this same time that Crawford was appointed to the Washington Ad Hoc Committee developing criteria for the determination of brain death. Responding to widespread public controversy over heart-lung death and brain death, Crawford urged that committee to adopt guidelines allowing each patient to choose his own definition of death. However, this well-intentioned proposal had a tragic end when Crawford's ill graduate student, misinterpreting Descartes, became convinced that when he was unconscious he did not exist. Thus after drinking himself into a stupor one afternoon he was pronounced dead and taken off dialysis. (Ironically, Crawford had become convinced that the student would probably not do very interesting work and had recommended that he be taken off the dialysis anyway.)
Because of Crawford's work on the Washington committees, he was appointed to the membership of several presidential commissions on bioethics, including the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Crawford is perhaps best remembered for his famous observation that the members of that committee, who came from diverse cultural and religious backgrounds, had no difficulty reaching ethical agreement as long as they limited their discussion to particular cases and did not talk about low-fat diets, folk dancing or pony-tails on men. But it is often forgotten that he was chair of an earlier committee called the National Commission for Recommendations on the Possible Use and Abuse of the Safeguarding of Human and Non-Human Subjects of Philosophical Experimentation and Research within National and International Colleges and Universities (NCRPUASHNSPERNICU). Crawford's committee only met a few times in a bar in Key West but in doing so came up with the first listing of the principles of bioethics. As Crawford often pointed out later, there were originally not four but five principles: Beneficence, Non-maleficence, Justice, Autonomy, and Adoration for Philosophers. Crawford has argued that the fifth principle -- possibly lost in a paper shuffle -- was the key to resolving most moral problems in health care settings. In his often cited piece in the (now defunct) Journal of Philosophical Medicine, "The Decline of Adoration," Crawford argued that since the medieval period, the general public has lost its adoration for philosophers. He noted that prior to the modern period, most philosophers were treated "as a combination of matinee idol, rock star, and IRS agent," and in the modern period, many have been forced to teach for a living. The rise of moral problems in the contemporary world, Crawford contended, could easily be remedied by returning to the Platonic idea of the philosopher-king. Later he argued that the principle of adoration for philosophers trumped all the others, and finally, he suggested that one could drop the other four principles altogether.
Photographs often show Crawford (a man known for his healthy appetite, and unusual choice of toupees) walking with a group of white coated residents. Although Crawford also believed that ethicists should wear lab coats to fit into the hospital world, he insisted that they be made out of tweed. (One of the authors of this essay -- TC -- is the proud owner of one of Crawford's coats, which were made by his fifth wife, the well-known medical anthropologist, Barbara Rauner.) Contrary to rumor, Crawford was not the first philosopher to teach bioethics in a hospital setting. However, he was the first philosopher to successfully bill a patient for a clinical ethics consultation. It was this early success that led to his eventual appointment as the Mr. Muffler Professor of Bioethics and Auto Repair at the Medical University of Saint Lucia, a unique arrangement which allowed him to collect for ethics consultation from a patient's automotive insurance agency. This might strike many as odd but Crawford pointed out that one of the principles of bioethics, respect for autonomy, was actually a mistranslation from the German, which should have been translated "respect for automobiles." At the time of his recent hospitalization Crawford was preparing an address on the controversial issue of "ethics licensure" to the Society for Health and Human Values in which he argued that ethicists should be allowed into hospitals only after receiving approval from the Department of Motor Vehicles. As with many battles in bioethics, this turned out to be more political than philosophical, for noted programs such as the University of Chicago's Maclean Center for Clinical Medical Ethics insisted that only trained mechanics be able to do ethics consultations. As Mark Siegler, who trained as a mechanic before entering medicine, pointed out, "One who has not felt the grease and oil of the muffler can not truly understand the dilemmas of the mechanic. The field has relied too long on so-called outside consultants, who know about cars only by reading popular car magazines." This debate should continue for some time.
Crawford helped found both the Hastings Center and the Kennedy Institute of Ethics at Georgetown University. He also made a name for himself in Canada by setting up the Centre for Transdisciplinary Studies at McGill University, which he funded with a $20 million endowment raised through cable TV contracts, contributions from pharmaceutical companies and a 1-900, bioethics psychic hotline. The Centre ingeniously avoided McGill's notorious political infighting by having no faculty, students, administrative staff or physical location. Later, however, Crawford came to consider the very idea of bioethics centers questionable, and began what became known as the Rockefeller Floating Ethics Extremity. This organization was located on a large floating barge that traveled along the rivers in the United States and later made trips to Cuba, St. Croix, and Saba. Many recall the tragic sinking of the barge in the late 1970's. Crawford escaped, along with Jim Childress, Daniel Callahan, Edmund Pellegrino and three representatives of the Association of Libertarian Surgeons, including Robert M. Sade. The group of them were left with only enough food and water for three. As Crawford later explained in his well-known article in the New England Journal of Medicine, "The Right Not to be Drowned and Eaten: A Refutation," Sade and his libertarian colleagues were sacrificed for the well-being of the group. Because of the controversy surrounding this incident, the Rockefellers pulled out all funding, but friends of Crawford stated that he maintained a fondness for libertarians.
Following the election of Bill Clinton to the U.S. presidency in 1992, Crawford, a close friend of Hillary Rodham, was asked to lead a task force on medical ethics associated with the reform of the U.S. health care system. Controversially, Crawford insisted that the ethical principles developed by his task force could not be revealed to the economists, as he thought this might sully the philosophical ideals. As one point Crawford argued that since so many Americans use emergency rooms as primary care facilities, U.S. medical schools should be required to direct 80% of their graduates into Emergency Medicine residencies. Ironically, it was Crawford's third ex-wife who starred as Louise in the infamous "Harry and Louise" ads.
Several years ago Crawford began developing a new television show called "The Ethicist," in which he planned to star. Noting that many Americans were seeing moral problems presented in the shows ER and Chicago Hope, Crawford planned a show in which a naive young clinical ethicist comes to an urban medical center to assist a crusty but lovable senior ethicist who is about to retire. Each week's episode would center on an ethical dilemma in which the old ethicist would show the inadequacy of new approaches to bioethics and how the four principles really do work. Crawford wanted the weekly shows to be based on real cases from his own experiences as a consultant such as "The Case of the Conjoined Twins who Need a Blood Transfusion But One of Them Is a Jehovah's Witness." Early last year Crawford sold the rights to the show to ABC. However, he angrily withdrew from the project several months later when he was removed from the starring role and replaced by Art Caplan.
Many readers may not be aware of the tragic accident in the Caribbean last July that led to Crawford's current hospitalization. Crawford was well-known in the field of bioethics for the annual "bioethics summer retreats" (or "university-funded vacations", as the attendees fondly called them) which he began organizing in late 1980s. Perhaps the most renowned event at these retreats was the annual "running of the bulls" in which a group of medical humanities scholars were forced to run from various well-known ethicists who had horns attached to their heads. (This practice was stopped when Professor Howard Brody kept goring himself.) During the 1997 retreat in Saint Lucia, Crawford was part of a group undertaking a recreational expedition through a coastal cave. At one point he and an anonymous female assistant professor from Malibu apparently wandered off from the group, and Crawford got stuck in a narrow passageway, thereby trapping the entire expedition in the cave. A long debate began as the various ethicists argued whether killing Crawford was a reasonable action to save their own lives. A couple of graduate students argued for killing Crawford on utilitarian grounds, pointing out that his death would free up a job, a large number of positions on editorial boards, an extensive collection of French wine in his home, and his first-class return air ticket. Albert Jonsen noted the large number of similiar cases in the literature of overweight senior ethicists who had trapped their colleagues in caves. The entire group might have been killed by rising tides if not for a freak accident involving a runaway trolley filled with South American villagers which derailed into the cave and dislodged Crawford from the passageway. Although he was seriously injured, Crawford was kept alive after the accident through life-support systems which connected him to the violinist Itzhak Perlman. However, Perlman disconnected himself after finding out what Crawford did for a living, and as a consequence Crawford lapsed into a persistent vegative state. Obviously, the ABMH Lifetime Achievement Award cannot be given directly to Crawford at this time. However, his seventh wife, the well known performance artist, Epoche, has agreed to accept it on his behalf. Crawford's neurologist, Dr. Ron Cranford, has stated that Crawford has no hope of recovery, but a friend of Crawford's father who has been doing important work in South American has agreed to try to clone him. Crawford's twelfth child, Plotinus Crawford, believes that with the correct nurture, the new Crawford may be able to receive an additional lifetime achievement award. On behalf of the ABMH award committee, we wish once again to congratulate Crawford and his family on this honor.