Words: 2002
Nineteenth-Century Codes of Medical Ethics History shows that the nineteenth century had been a period of considerable progress in various fields – including the field of medicine. While it is safe to say that the foundation of what we understand as modern medical ethics is rooted in the Scottish Enlightenment during the eighteenth century (Vetch 2005, 4), it was during the nineteenth century when these ideas found entry and were applied into codes for the regulation of medical practice.
These codes of the nineteenth century had received broad scholarly attention In the past. A reason for this might be that we find not few remnants of them In today’s medical ethical regulations. The purposes and the effectiveness of such codes are still being discussed vividly amongst scholars and a clear answer is yet to be found. In this paper I will argue that a general answer to the question about the purpose for the nineteenth century codes of medical ethics cannot be carelessly given.
Instead I will show that the constitution of such codes was In each case a dynamic reaction to specific and unique circumstances. However, as I will argue there are injections between each of the codes amongst which the most obvious would be their shared source – I. E. The work of Thomas Percival. I will develop my argument by working through the most exemplary codes of the nineteenth century chronologically. It is necessary to start out by introducing the physician and author Thomas Percival, whose work Medical Ethics served as the inspiration for almost all subsequent codes.
I will then give a short overview of the most Influential codes -?? that are the Boston Medical Police (Bibb the American Medical Association’s Code of Ethics (1847), and in England Juke Strap’s A Code of Medical Ethics (1878). By analyzing some examples of the works and the research done on them want to find out more about their purposes. At last I will focus on the effects these codes had on the nineteenth century world of medicine and I will show that the direct effectiveness of the codes varied from case to case.
Nevertheless I will argue that these codes were effective In a broader sense. They strongly helped the constitution of the medical practice as a profession – an effect probably not explicitly intended by the authors. Thomas Percival and his Medical Ethics (1803) By tracing back the developments of Medical Ethics one definitely comes across the work of Thomas Percival. In the eighteenth century medical conduct was strongly based on the “practitioner’s honorable and virtuous character” (Baker 1999, XSL).
Medical scholars such as John Gregory wanted to teach their students a sense of “the identity of personal and professional honor” (Baker 1 999, xiv). This vague way of moral regulation on the basis of gentlemanly honor was problematic because inter- physician professional arguments could easily develop into personal quarrels. Thomas Percival was working at the Manchester Infirmary when an argument between the staff arose.
He was then asked to prepare a setoffs rules to prevent such colleagues was his work Medical Ethics, published for a broader audience in 1803. The four chapters of the paper present guidelines for conduct in hospital practice, private or general practice, in dealing with apothecaries, and concerning legal matters. In addition to the urgent situation regarding the cooperative problem at the Manchester Infirmary, Percival himself provided us with an account about his motivation for publishing his work.
He was induced “by an earnest desire to promote the honor and advancement of his profession and frame a general system of medical ethics; that the official conduct, and mutual intercourse of the faculty, might be regulated by precise and acknowledged principles of urbanity and rectitude. ” (Quoted by Vetch 2005, 63) And as I will show, this aspiration turned out to become true. Boston Medical Police (1808) After having talked about the most influential ethical work regarding modern medical ethics I want to draw the attention to the first codes of medical ethics, which appeared in the early nineteenth century in America.
Then it was a trend amongst a group of American physicians and intellectuals to “revivalist old European medical ideals and reinvent them into the newly formed United States” (Baker 1995, 2). After the profession grew and a lot of municipal and state medical societies were formed it became customary for these societies to set up their constitutions. The first of these to be appended had been the Boston Medical Police in 1808, which was declared influenced by the ideas of Gregory, Percival and Rush.
It is to be mentioned here that here still is a debate among modern scholars whether this document could be read as medical ethics or mere trade union regulations. In distinction to Percival work these police’s brief nine sections deal entirely with physician-to-physician relationships – the physician-patient relationships are completely left out. This might be a hint towards the purpose of this police: the mutual attitude – the consultations – between practicing physicians was problematic and needed guidance.
The reason for these problems might be found in the structure of the profession during that time. Since almost all physicians did the same sort of things, consultants were ordinarily potential competitors. ” (Rosenberg 1967, 223-253) Also Rottenest emphasizes the dilemma nature of consultations as “a major source of conflict among physicians” (Rottenest 1972, 83). In this sense the Boston Medical Police – Just like Percival early version of his work -would have been “intentionally designed to resolve a cooperative dilemma” (Baker 1995, 31).
The American Medical Association’s Code of Ethics (1847) The development of the mentioned societies culminated in the formation of the American Medical Association and the adoption of a national code of medical ethics in 1847 (CB. Baker 1995, 2). Drawing on Percival work but also including America- fitted ideas of Benjamin Rush, the 1847 code used the principle of reciprocity to justify “consensual professional authority’ over the behavior and practice of members.
I believe Baker is correct to emphasize the innovative element of this code that through this reciprocity the physicians were provided with rights against their into three chapters: Chapter 1 -?? Of the Duties of Physicians to Their Patients, and of he Obligations of Patients to Their Physicians; Chapter 2 -?? Of the Duties of Physicians to Each Other and to the Profession at Large; and Chapter 3 -?? Of the Duties of the Profession to the Public, and of the Obligations of the Public to the Profession.
Each of these chapters was subdivided into articles that outlined the roles and responsibilities of doctors, patients and society and provided the agenda for reforming medical education and medical practice in America. This became the foundation of medical education and quacks, charlatans and non-orthodox restrictions were not only to be removed from membership in local and state medical societies but the members of such societies were forbidden to consult with them (CB. Article ‘V, Section 1).
There has been great dispute amongst scholars about the real purpose of this code. Some saw in it – especially in the exclusion of different medical approaches, for example homoeopathy -the longing of the Mama’s members for monopolizing and the acquiring of political power. Others interpreted the action by the AMA as a reaction to the demand for some form of unified educational program, s the following source supports: “Nobody knew who or what they were, except as they claimed, or as a surface view of their characters indicated.
Instead of taking to the highway and magnanimously calling upon the wayfarer to stand and deliver some unscrupulous horse doctor would set up his sign as “Physician and Surgeon” and draw his lancet on you, or fire at random a box of pills into your bowels, with a vague chance of hitting some disease, unknown to him, but with a better prospect of killing the patient, whom or whose administrator, he charged some ten dollars a trial for his marksmanship. (BALDWIN 1853, quoted by Baker 1995, 10-11) This extract gives an insight into the historic circumstances of the code.
The physicians had to make a living under almost entirely free competition. Untrained practitioners forced highly educated physicians to take unprofessional measures. Since distinct criteria to ensure proper medical treatment and distinguish quackery did not exist, it had to be developed. I believe the purpose of the constitution of the Mama’s code can be found in its historical context with the aim to establish a clear and distinguishable professional identity (CB. Frisson 1999, 127-128).
The code eventually led to a new standardized medical licensing system that dramatically accelerated the formation of an American medical profession. Jukes Strap’s A Code of Medical Ethics (1878) The situation in nineteenth century England differed notably. It was not until late in the nineteenth century that Juke Satrapy wrote the “only important code of medical ethics to be published in Victorian England” (Bavaria 1995, 145). The first edition was published in 1878 but revised and enlarged editions appeared in 1886, 1890, and 1895.
The new editions especially included “modern” aspects – for example railway deiced etiquette or advices for the consultation with homoeopath. As Bavaria explains further it was in 1882 when Satrapy offered his first edition to the British Medical Association. He had hoped that his Code would gain acceptance as the profession’s ethical standard. His idea was that these codes were to be sent to every Medical Association never accepted the offer and therefore Strap’s code never had any official standing within.
Nevertheless we know from sources that it exercised considerable influence. Satrapy provided four Justifications for his work in his reface. First, there supposedly existed a request for guidance and advice – especially among young physicians. Second, in America there was already a written code since 1847. Third, the British Medical Association was actually interested in establishing a code and had appointed committees for this task before. And fourth, there had been local societies with their own codes lacking important and unified details.
The code is heavily influenced by the Mama’s code and probably through that by Thomas Percival work – a fact that Satrapy did not deny (Bavaria 1995, 147). If we sky about the purpose of Strap’s work it is also best to look closely at the historical context – I. E. The late nineteenth century. The code can – in my opinion – be evaluated as an update of previous codes and ideas designed to meet the changed conditions of the lives and medical practice in this time. How effective were these codes? As I stated at the beginning of my paper I would not be well advised to give a general answer to this question.
If we would Just look at the example of a doctor who was expelled from two medical societies after having been charged for consulting with a moppet and additionally fee-splitting, and the hereon following inability of this certain doctor to conduct his profession in a satisfying way, we would suggest that medical codes were highly effective. But only the fact that the British Medical Association declined to accept any form of a firm ethical code – like Strap’s code – makes it clear that not every single code had the same degree of effectiveness.
We would be better advised to look at each code in its own unique context individually and then try evaluating the degree of effectiveness under different perspectives. However, I think that I was able to describe a developing process of professionalisms of medical practice during the nineteenth century – at least for America. A process closely connected to the formation of societies with codes of ethics – all in some way linked to Thomas Percival and earlier Enlightenment’s ideas – that helped setting up regulations and guidelines for medical practitioners and the medical profession itself. Baker, R. (deed. ).