Thomas Percival's Code of Medical Ethics
The First Attempt to Regulate the Medical Profession
Ever since ancient times, there has been a clash between ethics and medicine — between the obligation to tell the truth and the willingness to tell a lie. Balancing the idealism expressed in the Hippocratic Oath (physicians will act “for the benefit of . . . patients”) is the pragmatic realism of Plato. In The Republic, Plato acknowledged that physicians sometimes have good reason not to tell the truth: “If . . . a lie . . . is useful only as a medicine to men, then the use of such medicines should be restricted to physicians.” According to French (2003), Greek physicians were advised to turn away hopeless cases so as not to be blamed when the patients died. While this approach may have protected physicians, it did not assure patients that medicine was governed by rules or ethical regulations.
European Medicine Before the 19th Century
During the Middle Ages (10th-14th centuries), when many physicians were monks, the Church defined the doctor-patient relationship. Thus, whether or not a patient recovered from an illness had less to do with the skill of the physician than with divine authority. In this sense, ethics was decided by the unknown will of God.
The Age of Reason (17th century) began a shift away from faith to a more businesslike arrangement between physician and patient. Nevertheless, the ethics associated with telling the truth were largely ignored. In 1672, the French philosopher Samuel de Sorbiere advised young doctors that honesty with patients “was a danger to be avoided.”
By the Age of Enlightenment (18th century), all ties with the Church had been severed. As the lure of money influenced medicine, quackery began to supplant beneficial remedies. In fact, cures were sometimes offered for which no corresponding symptoms existed. In 1790, a visitor to the English city of Bath observed sorrowfully that he had “been cured of more diseases in a week than he had suffered in the rest of his life.”
Feud at the Manchester Infirmary
It is perhaps surprising that the medical profession did not have a formal code of ethics for thousands of years. At one time, however, the prevailing sentiment was that physicians were professionals and gentlemen who did not need to be told how to act or behave. Instead, physicians followed an informal code of conduct that was reassuring in theory, but problematic in practice.
In 1792, for example, the Manchester Infirmary witnessed a feud erupt among surgeons who held conflicting medical beliefs. Sparked by warring words in published pamphlets, the surgeons in the hospital went on strike — going so far as to turn away patients during a typhus epidemic. The hospital trustees were enraged at this behavior and commissioned a local physician by the name of Thomas Percival (1740-1804) to devise rules that would prevent such unprofessional conduct in the future.
Thomas Percival Drafts a Code of Medical Ethics
Thomas Percival was a respected anti-slavery advocate as well as a physician who had been practicing medicine since 1765. He was a staff physician at Manchester Infirmary when the epidemic broke out and was familiar with the surgeons involved as well as the immorality of the strike. Percival was given the task of forming a committee to suggest rules of conduct, which the hospital trustees adopted.
In 1794, the results were published as a slim pamphlet of practical guidelines for physicians. Nine years later, Percival revised and expanded his pamphlet into a book entitled, Medical Ethics; or, A Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons. Percival argued that in order for physicians to be considered professionals, they needed scientific knowledge and competence, a system of quality assurance and evidence, and a willingness to put a patient's welfare above self-interest.
Typical of its time, Percival felt that a physician’s obligation to tell the truth was not an absolute requirement but a relative duty, especially if the doctor felt that the patient would be unable to bear the truth. As Percival proclaimed: “To a patient . . . who makes inquiries which, if faithfully answered, might prove fatal to him, it would be a gross and unfeeling wrong to reveal the truth.”
The Influence of Thomas Percival
Percival's work did not die with him, but crossed the Atlantic Ocean and entered the mainstream of U.S. medicine in the mid-19th century. In 1847, the American Medical Association (AMA) was established in Philadelphia and published its own ethical code later that same year.
The first AMA Code of Medical Ethics was freely based on Percival’s work, sometimes borrowing liberally from its predecessor. The original AMA Code was 16 pages in length; the 2008-2009 edition is 504 pages, suggesting that modern ethical problems are exceedingly complex and in need of more physicians like Thomas Percival to solve them.
References
De Sorbiere S. 1672. Advice to a Young Physician Respecting the Way in Which He is to Conduct Himself in the Practice of Medicine. In: Jones KB. 2007. Surgeons' silence: a history of informed consent in orthopaedics. The Iowa Orthopaedic Journal. 27:115-120.
French R. 2003. Medicine Before Science: The Business of Medicine from the Middle Ages to the Enlightenment. Cambridge: Cambridge University Press.
Percival T. 1849 (3rd ed.). Medical Ethics; or, A Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons. Oxford: John Henry Parker.
Medicine Has Its Own Code of Ethics
|
More in Science & Nature
Latest Articles