Medical Codes and Oaths: I. History

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I. HISTORY

The following is a revision and update of the first-edition article "Codes of Medical Ethics: History" by Donald Konold. Portions of the first-edition article appear in the revised version.

In the ethics of healthcare, explicit statements of ethical standards have been formulated for physicians and members of the other health professions, for persons conducting medical experiments involving human subjects, for administrators, and for patients and other laypeople who make healthcare decisions. These have often been written by members of the relevant practitioner group, but they may also be written by members of religious, cultural, national, or international bodies. While codes of ethics have long been regarded as the classic expression of these directives, various principles and rules have also been stated in the form of prayers, oaths, creeds, institutional directives, and statements. Prayers state a very personal commitment of duty; oaths publicly pledge the oath taker to uphold specified responsibilities; and codes provide more comprehensive standards to guide the practicing health practitioner, patient, or other decision maker. Each form of ethical statement implies a moral imperative, either to be accepted by the individual personally or to be enforced by a practitioner organization, religious community, or governmental body.

While practitioner bodies have often assumed responsibility for writing their own codes of ethics for their members, governmental, religious, and cultural bodies have also claimed authority to articulate the moral norms of conduct in healthcare. Disputes over who has the authority to articulate codifications of ethical duties in the medical sphere reveal important controversies over who can legitimately claim moral authority in determining what these duties are. This article first examines prayers, oaths, and codes written by health providers or practitioner groups, and then examines those written outside the profession.

Documents Created by Practitioners

MEDICAL PRAYERS. Healthcare providers in all ages have composed prayers expressing gratitude for divine blessings and asking for divine inspiration in their practitioner conduct. Such prayers signify that the writer stands within a religious tradition and grounds medical duties in that religion's moral framework.

An ancient Greek poem that has the quality of a prayer or a hymn was found inscribed on a monument in a sanctuary of Asclepias, originally on the south slope of the Acropolis. According to the poem, the physician should be "like God: savior equally of slaves, of paupers, of rich men, of princes, and to all a brother, such help he would give" (Etziony, p. 21).

Likewise, ancient Jewish sources include texts extolling the physician's healing. An early Jewish prayer was written by the early-twelfth-century Spanish poet, philosopher, and physician Yehuda Halevi (Etziony). The most widely acclaimed Jewish example is the Daily Prayer of a Physician, once ascribed to the Jewish physician and philosopher Moses Maimonides (1135–1204) but now believed to be the work of the eighteenth-century German Jewish physician Marcus Herz (Rosner). In the manner of most medical prayers, the Daily Prayer asks for courage, determination, and inspiration to enable the physician to develop skills, meet responsibilities, and heal patients. It commits the physician to place duty to patients above the physician's own concerns and places the physician's healing in clear subordination to divine authority.

Many examples of Christian prayers of physicians exist from ancient and medieval times. More modern prayers sometimes reflect more eclectic, nondenominational perspectives. The theology expressed in the prayers of these physicians, who, theologically, are laypeople, is sometimes not an authoritative reflection of the tradition in which they stand.

OATHS FOR PHYSICIANS. In the ancient world physicians often expressed their ethical commitments in the form of oaths, which were an integral part of the initiation ceremony for medical apprentices. Like many medical prayers, ancient oaths reflect the physician's belief that success in the healing profession required an alliance with the deity in the treatment of disease. The ancient oaths often beseech the deity to inspire physicians to fulfill their moral obligations, reward those who honor their sacred trust, and punish those who violate it.

One of the oldest of these oaths, a medical student's oath taken from the Charaka Samhita manuscript of ancient India, contains concepts that had pervaded Indian ethical thought for many centuries before their inclusion in the oath at about the beginning of the common era (Menon and Haberman). Pledging the medical student to live the life of an ascetic and a virtual slave of his preceptor in accordance with Indian custom for apprenticeships, the path requires personal sacrifice and commitment to duty from the student comparable to the physician's responsibilities to patients. By the terms of the oath, the student physician is to place the patient's needs above personal considerations, serving day and night with heart and soul; abstaining from drunkenness, crime, and adultery; and scrupulously observing practitioner secrecy.

In sharp contrast to the medical ethics of the Western world, the Indian oath obliges the physician to deny services to enemies of his ruler, evildoers, unattended women, and those on the point of death. Ancient Indian thought condemned aid to anyone who was immoral or was involved in any circumstance that might suggest illicit sexual contact; it also condemned interference with the process of dying. Despite these differences, the oath of the Indian student reveals significant parallels between the medical ethics of India and those of the Western world, which may suggest a diffusion of ideas, probably from India to the West.

The most enduring medical oath of Western civilization is the Oath of Hippocrates. Despite its renown, its origin is obscure. It is a part of the Hippocratic Collection, which was catalogued and edited by a group of Alexandrian librarians sometime after the fourth century c.e. Copies of these writings available to modern scholars, however, date from the tenth to the fifteenth centuries c.e. and do not preserve the original text with verbal accuracy. None of the manuscripts in this collection can be positively verified as genuine works of the great Greek physician, and clearly the documents are the products of many contributors, with the earliest predating the latest by at least a century.

Twentieth-century scholars, especially Ludwig Edelstein(1943), have suggested that the oath conforms closely to the teachings of Pythagoras (fourth century b.c.e.). He noted the similarities with the principal ethical beliefs of the Pythagoreans, which included reincarnation, avoidance of shedding of blood, prohibition on taking of life, and commitment to sexual purity and secrecy. Edelstein held that the oath was composed by a group of Pythagoreans who practiced the healing arts. More recent historians of medical ethics have argued over whether the dependency is as close as Edelstein maintained, suggesting that the influence of other philosophical/ethical traditions may also be present (Carrick). Nevertheless, some degree of affinity of Hippocratic with Pythagorean thought is generally conceded. The oath, in accord with Pythagorean ethics, proclaims a more strict morality for physicians than was established by Greek law, Platonic or Aristotelian ethics, or common Greek medical practice.

The Oath of Hippocrates consists of two parts, the first serving as a contractual agreement between pupil and teacher and the second constituting an ethical code. The opening sentences pledge the novice physician (invariably a male) to become an adopted member of his teacher's family, to help support his teacher and his teacher's children in case of need, and to instruct his teacher's children free of charge. The oath forbids sharing the precepts and medical knowledge with anyone who has not taken the oath. Since familial bonds between teacher and pupil implied careful selection of those admitted to the family group, the covenant enabled physicians to prevent unworthy persons from entering the profession and to keep tight control on knowledge transmission.

The ethical code contained in the Oath of Hippocrates places restrictions on the medical techniques of the physician and defines relations with the patient's family. One who takes the oath pledges, "I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice" (Edelstein, 1943,p. 3). He also agrees to refuse to dispense poisons or abortive remedies, and to leave surgery (including lithotomy or removal of a stone from the urinary bladder) to those trained in that art. He makes the commitment that "whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice" (Edelstein, 1943,p. 3). The taker of the oath swears to abstain from sexual relations with all those in the houses the physician enters. Regarding confidentiality, in an ambiguously qualified way, the physician promises not to disclose that "which on no account one must spread abroad." The oath ends with a plea for reward that is unusually self-serving for a code of ethics: that if the physician keeps the oath he be "honored with fame among all men for all time to come." If he transgresses it, "may the opposite of all this be my lot" (Edelstein, 1943, p. 3).

The oath's provisions contrast sharply with what is otherwise known about ancient Greek medical practice, which permitted physicians to abet suicide and infanticide and to perform surgery. They introduced an element of respect for slave as well as freeman and, even though the secrecy requirement is qualified, it is extended outside the practitioner relationship. These precepts, though they represent the thought of only a small group of medical practitioners, extended their influence beyond the importance of the Hippocratic school of medicine in the ancient world.

For centuries following the appearance of the Hippocratic oath, the practitioners of the medical art showed no inclination to accept it. Hellenistic physicians ignored its injunctions without compunction. It is sometimes held that the rise of Christianity, which had certain ethical positions similar to Hippocratic ethics, is responsible for the ascendancy of the Hippocratic oath (Edelstein, 1943; Carrick). There is, however, very little evidence of early Christian interest in the Hippocratic oath; increasingly there is emphasis on important ethical differences between the Hippocratic and Christian traditions (Veatch and Mason). Medical historian Owsei Temkin has identified considerable tension between Hippocratic and Christian medicine and their ethical commitments. One exception to this generalization is the fourth-century Christian figure Jerome, who explicitly mentions the Hippocratic oath, but in doing so he points out that the Christian physician's obligation is even more stringent.

Precisely what happened to bring the oath into prominence during the Middle Ages is uncertain. Perhaps the early post-Constantinian Christian culture found similarities between Christian and Hippocratic views, as has been suggested. A strong case can be made, however, that although there were significant differences between Greco-Roman and Christian medical ethics, lay physicians were simply not sufficiently schooled in Christian theology to perceive them.

One way or another, increased attention to the oath led to renewed interest in it. Modifications were introduced in order to bring it somewhat more into harmony with Christian ideological concepts and practices. This could be taken either as evidence to support the convergence hypothesis or to support the contrary claim that the oath had to be corrected significantly to bring it into harmony with Christian thought.

The earliest of these extant revisions, titled "From the Oath According to Hippocrates Insofar as a Christian May Swear It" (dating from the tenth or eleventh century), substitutes a statement of Christian adoration of God for the references to the Greek deities in the original oath and replaces its covenant with a statement of teaching responsibilities based on Christian brotherhood, pledging the physician to teach the medical art to whomever wants to learn it (Jones; Leake). The injunction against surgery does not appear in this version of the oath. No reason is known for its omission, but later Christian versions do contain it. The appeal for reward and honor for the physician should he follow the oath is abandoned, probably because it is inconsistent with Christian views of grace.

The Oath of Asaf, from the seventh-century Sefer Asaf manuscripts of the oldest Hebrew medical work, reveals Hippocratic influences in its injunctions against administering poisons or abortifacient drugs, performing surgery, committing adultery, and betraying practitioner confidences (Rosner and Muntner). Like the medieval Christian oaths, it is consistent with Talmudic ethics and instructs physicians to give special consideration to the poor and needy, a concern absent from the Hippocratic oath. A revision of the Oath of Hippocrates also appeared in medieval Muslim literature, where the only significant changes replaced references to Greek gods with statements in harmony with Islamic theology. The oath in its original form was also known to Christian and Muslim scholars; however, among the Christian church fathers, only rare mention is made of it. The texts that do refer to the oath reveal a perception of a difference between Hippocratic and Christian medicine.

Following the transition from medieval to modern Western civilization, the Oath of Hippocrates apparently continued to be a model for ethical pledges by physicians. Its legacy is ambiguous. On the one hand, it repudiates exploitation of the sick, often the most vulnerable. On the other hand, it locates all authority about what constitutes a benefit in the physician's "ability and judgment." In this way, the oath has sanctioned a medical paternalism throughout the ages that is in conflict with the modern assertion of the right of patients to determine for themselves the benefits they seek from medical care.

Western medical schools in the eighteenth and nineteenth centuries, seeking to impart high ethical ideals to their students, administered oaths to their graduates. It is unclear whether or how often the Hippocratic oath itself was used, but certainly the typical oaths, such as that of the great medical school of Montpellier, incorporated Hippocratic ideas (Etziony).

Our knowledge of professional medical ethics in the early modern period is very limited. Historians have not done enough specific research in European and American medical schools and professional societies to know what local religious, philosophical, and political influences helped shape medical education. Additional research is underway. The received tradition holds that Western medical schools, seeking to commit their students to the pursuit of high ethical ideas, continued a tradition begun in the Middle Ages of incorporating Hippocratic concepts in oaths for their graduates, especially the covenant's requirement for the physician to instruct his teacher's children and the ethical injunctions for secrecy and against administering harmful drugs. During the nineteenth century, some medical schools in the United States required their graduates to take the Hippocratic oath in its original form, and that continued to be a common practice in the twentieth century, even though many of the oath's provisions were archaic or offensive to some of the students. A study published in 1991 found that 60 of 141 U.S. medical schools administered the Hippocratic oath (Dickstein et al.).

A document patterned after the Oath of Hippocrates appeared in 1948, when the newly organized World Medical Association (WMA) adopted the Declaration of Geneva. In 1991 forty-seven U.S. medical schools used it (Dickstein et al.). (Of the remainder, fourteen schools used the Prayer of Maimonides or more recently written oaths.) The declaration attempts to make the original oath applicable to modern conditions of medical practice and diverse cultural, religious, and ethnic groups in the world community. In doing so, it raises serious questions of how any one single ethical text could be made appropriate for a wide range of religious and cultural groups that clearly have fundamental differences, not only about significant medical ethical controversies, but also about the very foundations and meanings of ethical propositions. The Declaration of Geneva is a secular oath that contains no reference to religious tenets or loyalties, thus appealing to secular physicians while perhaps offending those who continue to ground their ethics in some particular religious framework.

Although the claim is made that the Declaration of Geneva simply updates the Hippocratic oath, the reformulation clearly involves significant differences. The declaration commits the physician to make the patient's health his or her first consideration, a provision reminiscent of the Hippocratic oath's pledge to use dietetic measures for the benefit of the sick. But in addition to the secularization of the declaration by the removal of the religious references, the 1948 text deletes the pledge to refuse to reveal information to those who have not taken the oath. The loose Hippocratic pledge of confidentiality is replaced with an exceptionless pledge, one that conflicts with the increasingly recognized necessity of disclosing in order to protect third parties from serious threats of harm, as well as with the more paternalistic exceptions seen in many modern interpretations of the oath. The oath's surgical restriction is also omitted from the declaration, as is the injunction against sexual contact with those in the patient's household.

The physician of the declaration vows not to let considerations of religion, nationality, race, party politics, or social standing interfere with his duty to his patient. Obviously, those who conceived and adopted the declaration found united support for clearer condemnation of these prejudices than the original oath provided. In sharp contrast, however, the declaration's statement of the physician's responsibility regarding suicide, mercy killing, and abortion is obscured in generalities that conceal modern controversy on these matters among physicians and laypeople alike. The physician of the declaration pledges only to maintain respect for human life from the time of conception and not to use medical knowledge in ways that are contrary to the laws of humanity. While the Declaration of Geneva has found some acceptance among medical professional groups, it has not been endorsed by significant national professional associations, and it certainly conflicts with the ethical precepts of many secular and religious groups in both East and West.

PRACTITIONER CODES. Physicians of the modern world have not been content with the spiritual inspiration of prayers and the moral commitments of medical oaths. The large medical institutions of urban society have required complex relationships among medical personnel who demand detailed procedures to prevent embarrassing ethical controversy and disruption of services. Lengthy treatises on medical subjects, which had enlightened physicians on ethical matters since the earliest times, were not easy to cite by paragraph and line and frequently concealed ethical instruction in needless verbiage. Reducing these essays to lists of rules, proponents of practitioner control produced elaborate ethical codes.

A code is an ordered collection of injunctions and prohibitions, usually created by an authoritative body and adopted as a statement of ideals and rules for a group or organization. The modern idea of codes derives ultimately from the Renaissance ideal of rationalizing Roman law, putting the diverse parts into some order and stating briefly and clearly the essence of the rule. Sometimes individually authored documents, such as the work of Sun Szu-miao and Thomas Percival discussed below, have taken on the status of systematic codifications.

One of the earliest codes of medical ethics appeared in China, where the Oath of Hippocrates never made a significant impression. From the seventh century, an indigenous Chinese tradition in medical ethics developed in works by Sun Szu-miao. Generally regarded as Taoist, his writing stresses the importance of preserving life and the subordination of self-interest to compassion for the patient. It reflects the differentiation of an elite group of physicians referred to as "great physicians" and marks the emergence of a group claiming special medical authority. A Confucian response authored by Lu Chih (754–805) attacks this elitist trend, indicating medicine should be the responsibility of all persons. This tradition received clear expression in the Five Admonitions and Ten Maxims listed by Ch'en Shih-kung in a seventeenth-century treatise on surgery (Unschuld). Along with much guidance for social intercourse, Ch'en's precepts instruct physicians to give equal treatment to patients of all ranks, to keep expenses modest, and to treat the poor without charge, providing the same services regardless of the amount of payment. Above all, the physician is to know the principles of Confucianism. The key Confucian virtues are compassion and "applied humaneness," terms that do not enter Western medical ethics until the twentieth century.

These instructions continue to characterize Chinese medical ethics in modern times, but they have had little influence elsewhere. Although they bear some resemblance to ethical concepts in Western medicine, there are significant differences and little evidence of crossfertilization.

In the West, the Royal College of Physicians provides an interesting example of a professional code. In the first Statutes of the College in 1555, and in the revision of 1647, there is a section entitled, De statutis moralibus seu penalibus. This contains precepts requiring good behavior in the meetings of the college, regular attendance and, in addition, proper etiquette between several physicians called into consultation. They admonish physicians not to disparage or accuse one another in public, but only before the college. They also prohibit physicians from telling their patients and the public the names and composition of medicines, "lest the people be harmed by abuse of them" (Clark, p. 384).

A treatise published in 1803 by Thomas Percival, an eminent physician of Manchester, England, strongly influenced the development of codes of medical ethics (Leake; Baker et al., 1993; Baker, 1993). Originally prepared in 1794 to mediate a dispute among surgeons, physicians, and apothecaries in Manchester, and expanded in 1803 to include physicians in general practice, Medical Ethics; or, A Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons expresses standards of morality and etiquette that were in sharp contrast to the quarrelsome conduct of British practitioners of that era. Percival's treatise places emphasis on the professional relationships of physicians to one another; to hospital personnel, apothecaries, and others engaged in the care of the sick; and to the law.

In its advice to physicians to treat patients with the eighteenth-century virtues of "tenderness, steadiness, condescension, and authority," it conveys the attitudes of the English gentleman philanthropically bestowing benefits on patients who are expected to show proper gratitude. Percival's Medical Ethics stands in the Hippocratic tradition, but begins to acknowledge obligations of physicians to the society as well as to patients. Unlike the Hippocratic oath, Percival holds both surgery and medicine as acceptable practices.

As befits a volume having its origins in a local dispute among professions, a principal concern of Percival's Medical Ethics is with the etiquette of professional conduct. It offers elaborate procedures for consultation among physicians in difficult cases and for preservation of distinction of rank in relationships between junior and senior physicians on hospital faculties and in consultations. It cautions physicians to display respect for one another, to avoid criticizing the practice of their colleagues, to conceal professional differences from the public, and not to steal patients from one another. In justifying these procedures, Percival reasoned that criticism of the profession was usually unfounded and always degrading both to the doctors criticized and to the profession. In most of its provisions, Percival's Medical Ethics suggests a modified utilitarian philosophy, calling for individual physicians to conduct themselves in a manner that would enhance public respect for the entire medical profession.

Among the earliest American writings in physician-authored ethics were those by Columbia University physician Samuel Bard and revolutionary patriot Benjamin Rush; early codes were also prepared by the medical associations of the cities of Boston and Baltimore and the state of New York. When the American Medical Association (AMA) was organized in 1847, it adopted a code of ethics drawn from Percival's Medical Ethics as well as these other sources. The code of ethics made no mention of etiquette for hospital staff and barely referred to the relations of physicians with pharmacists and courts of law, but it expanded and elaborated the principles for physicians in private practice, even presuming to include a statement of obligations of patients and the public to physicians.

The medical profession in the United States faced a crisis in public confidence in 1847. Medical licensure laws in most states had been repealed with the result that uneducated practitioners and charlatans had begun to compete for patients with educated physicians. In addition, a vigorous debate raged between various schools of medical science over which was the correct or orthodox system. Proponents of the code of ethics hoped that the public would cooperate with allopathic physicians in establishing standards for medical practice that would reinstate public respect for the medical profession.

The code of ethics contained a variety of restrictions on open competition among physicians. It branded as quacks all medical practitioners who lacked orthodox training, claimed special ability, patented instruments or medicine, used secret remedies, or criticized other practitioners. In doing so, it also became a weapon in the internal dispute among physicians of different schools, particularly challenging the homeopaths. The requirement of orthodox training made outcasts of physicians who belonged to medical sects such as the homeopaths, the eclectics, the Thomsonians, and later the osteopaths and chiropractors. Since each sect claimed superior results from its form of treatment, practitioners with sectarian designations were guilty of claiming superior ability as well as handicapped by their incomplete education.

Charging that these offenses resulted from selfishness and efforts to discredit rivals, the code of ethics also demanded that reputable physicians avoid any appearance of soliciting the patient of another doctor. Although these provisions united the profession against heterodoxy and quackery, the prohibition on claims of special ability produced conflict between general practitioners and aspiring specialists. This ethical rule ceased to cause dissension only after the establishment of specialist organizations to certify the credentials of their members and after specialization won sufficient acceptance to permit physicians to restrict practice to their specialties.

The code of ethics provided orthodox physicians with one means of exposing those undeserving of confidence. It stated that physicians should not consult professionally with anyone who lacked a license to practice or was not in good professional standing. Since professional standing was determined by the local medical societies, this provision had the effect of substituting a collective professional judgment for that of individual physicians and patients, thus superseding the Hippocratic oath's focus on the individual physician's judgment. In those cases where the patient insisted on inviting a consultant who was not approved by the local medical organization, the attending physician would have to retire from the case in order to retain professional standing. While physicians argued that they could not fulfill their obligation to patients if they admitted a right for fraudulent practitioners to advise in any capacity, their ethics required that they withdraw, thus giving full charge of the case to the allegedly unqualified practitioner. Moreover, the majority of physicians found the consultation restriction a useful means for excluding many qualified physicians from association with the dominant organization. Thus the codes served a monopolistic function as instruments for restraint of trade. Before 1870, regular medical societies excluded from membership and forbade consultations with female physicians and Negro physicians and, throughout the latter half of the century, with physicians who adopted a sectarian designation, even if they were certified by licensing boards. Because of mounting criticism, the consultation restriction was eliminated from the code of ethics in 1903, but its spirit was revived by a 1924 resolution of the American Medical Association forbidding voluntary association of its members with cultists. In effect, the AMA code, so vociferously debated in the nineteenth century was double edged: It did state, in Percivalian terms, certain ideals of good practice, but at the same time, it was an instrument to create a monopoly.

Establishment of the World Medical Association in 1948 encouraged physicians to develop international standards of medical ethics. The new organization adopted an International Code of Medical Ethics (International Code) in 1949, which attempted to summarize the most important principles of medical ethics. Since 1900, certification laws had reduced the prevalence of unqualified medical practitioners, and scientific advances had increased the effectiveness of trained physicians. By mid-century, physicians were directing their attention more to the actual treatment of patients and less to the formality of relations between one doctor and another, or between doctor and patient. The International Code reflects these new concerns in a shift away from the detailed regulations of the preceding 150 years. In place of elaborate etiquette for consultations and other medical confrontations, it recommends only that physicians behave toward colleagues as they would have colleagues behave toward them, that they call specialists in difficult cases, and that they not entice each other's patients. It warns against the profit motive and prohibits unauthorized advertising, medical care plans that deprive the physician of professional independence, fee splitting or rebates with or without the patient's knowledge, and refusal to treat emergency cases. It also commits physicians to honor professional secrecy in an unqualified way, an obligation that continues after the death of the patient, according to an amendment to the code adopted in 1968.

The International Code only hints at the ethical problems of abortion and euthanasia by asserting the physician's responsibility to preserve life. It does, however, warn specifically against any action that would weaken the patient's resistance without therapeutic justification. Applicable to the dying patient and experimental subject alike, this standard requires the physician to consider the patient's wellbeing above all else. The International Code also recognizes the need for adequate testing of innovations by urging great caution in publishing discoveries and therapeutic methods not recognized by the profession.

Using the International Code of Ethics as an example, the American Medical Association reduced its elaborate code to ten one-sentence Principles of Medical Ethics in 1957 (Ten Principles). This was intended as an epitome rather than a reduction. ("Every basic principle has been preserved," according to the Council that submitted the draft.) It retained the essentially Hippocratic focus on benefit of the patient, but added that the responsibilities of the physician extend also to the society.

Most of these principles had been anticipated in the International Code, but there are a few noteworthy exceptions. Reflecting a continuing distrust of sectarian practitioners by regular physicians in the United States, the 1957 principles warn against professional association with unscientific practitioners. They also oblige physicians who are AMA members to expose the legal and ethical violations of other doctors. Instead of warning against premature publication of discoveries, the 1957 principles urge physicians to make their attainments available to patients and colleagues. Finally, while reaffirming the principle of confidentiality, the 1957 principles authorize physicians to violate this principle when required by law or to advance the welfare of the individual or the community. This provision suggests more discretionary authority for the physician than do the codes of most nations and the World Medical Association, which emphasize the inviolability of professional secrecy.

By the late 1970s, there was again dissatisfaction with the principles. A special committee was appointed to prepare a new draft that would clarify and update the language, eliminate reference to gender, and seek a "proper and reasonable balance between professional standards and contemporary legal standards in our changing society" (American Medical Association, 1989, p. viii). The report submitting the new version acknowledged the increasing recognition of laypeople's role in defining the moral terms of the patient–physician relation. Nevertheless, the new code was prepared and adopted by a group made up entirely of members of the association. The new principles affirm the virtues of compassion and respect for human dignity. It, for the first time, shifts to the use of the language of "rights," saying that "a physician shall respect the rights of patients, of colleagues, and of other health professionals" (p. ix). It generally removes the traditional Hippocratic paternalistic authorization for physicians to act for the benefit of the patient according to the physician's judgment. For example, it permits breaking confidentiality only "within the constraints of the law" (p. ix).

Scientific advances and changing social standards in recent decades have raised ethical questions in a number of areas that are not adequately covered by existing general codes. The Council on Ethical and Judicial Affairs of the American Medical Association regularly issues opinions that elaborate (and occasionally contradict) the principles adopted by the AMA's legislative body, the House of Delegates. In recent years, other medical organizations, such as the American College of Physicians, have prepared and issued codes of ethics for their members.

Codes from Outside the Profession

GOVERNMENTAL CODES. In the twentieth century, a number of national governments have incorporated ethical codes into legal statutes governing the medical profession, to be enforced by an official, publicly appointed medical board. The precepts in these codes sometimes accord with the broader principles of the Percival tradition, but many provisions deal with problems of recent origin and reflect a modern concern for both public and individual welfare.

Some of these codes deal with single subjects. For example, the Nuremberg Code, which is the product of international law, deals with medical research on human subjects. In the United States, the federal government's regulations on the same subject function as a code of conduct as does the Belmont Report, a set of ethical principles on research developed by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978).

Underlying the development of these codes is a fundamental issue of ethics: Is the professional group or the general public responsible for deciding what the ethical norms of the lay–professional relation should be? Even if the profession is deemed the proper authority for determining what constitutes ethical conduct, it is not clear exactly who should have the authority to speak for the profession and what the content of the codes should be. Some functions of the codes are clearly more for public relations and control of competition rather than for articulation of ethical norms. Many provisions that clearly are normative in content are still controversial. It is increasingly doubtful that the organized professional associations should have the authority to speak even for the profession as a whole (including the large numbers of physicians who are not members of the organizations) and that these groups should have any authority to speak on ethical matters that affect laypeople.

While modern medical ethics has often presumed that the profession should define its own code of conduct, this has not always been the case. Religious as well as governmental groups have sometimes claimed this prerogative. Increasingly, professional groups as well as laypeople are insisting that judgments about ethics are not the exclusive province of the professions and that the norms of lay–professional relations should be grounded in cultural, philosophical, or religious commitments.

A government-sponsored medical oath was adopted in the former Soviet Union, where its Presidium approved the Oath of Soviet Physicians in 1971. Modeled after an oath that had been used at the University of Moscow since 1961, the Soviet oath pledged the physician to conduct himself in accordance with communist principles and to order his responsibility to the Soviet government. This commitment to political creed and government was unique among medical oaths. The Soviet oath did not neglect other moral obligations, however; it instructed the physician to honor professional secrets, constantly improve knowledge and skill, always be available to calls for medical care or advice, and dedicate all knowledge and strength to professional activities. Like other recent oaths, the Soviet oath voiced virtually the same ideal of humanitarian duty to individual patients that appears in the earliest medical creeds, but it also pledged the physician to serve the interests of society.

Postcommunist Russia is undergoing a major reassessment of its healthcare policies, including its medical ethics (Tichtchenko and Yudin). In November of 1991, the Russian Supreme Soviet adopted the Declaration of Rights and Liberties of Citizens, which includes the principle of voluntary consent for participation in medical experiments and declares a right of every citizen to qualified medical care in the state healthcare system.

The Russian Medical Academy has developed a "Solemn Oath" (1993) to replace the Oath of the Soviet Physician. The new oath is a modernized revision of the Hippocratic oath. Approved by the Minister of Health in 1992, it is an official government document, not merely the product of a professional medical association.

NONGOVERNMENTAL GROUPS. Throughout history, codes, prayers, and oaths dealing with medical ethics have also been sponsored by private groups, religious bodies, and consumer groups that do not represent the medical profession.

For centuries, the Catholic church has articulated moral views about medical matters including abortion, euthanasia, and fertility control. These have appeared, at least since the medieval era, in systematic theological treatises, cases of conscience (collections analyzing morally perplexing cases), and in the theology manuals of the early modern era (Kelly; Griese). Formal codes of medical ethics, such as the Ethical and Religious Directives for Catholic Health Facilities prepared by the United States Catholic Conference (1975; Griese), are not only considered binding on Catholics but also affect non-Catholics who are associated with Catholic health facilities and others who find their reasoning persuasive.

The statements of the directives on secrecy, consent, organ transplantation, and terminal care closely resemble those of other codes. It prohibits abortion, except when justified by the principle of double effect, that is, when it is an unintended result of a procedure employed to protect the mother. It prohibits both male and female sterilization except in the treatment of a serious pathological condition, and it prohibits artificial insemination. Thus, the directives articulate the Vatican's "Instruction on Respect for Human Life" (Sacred Congregation for the Doctrine of the Faith).

The modern consumer movement has also influenced the ethics of medical practice. As hospitalization became a major consumer service, consumers increasingly demanded the right of patients to minimum standards of care and respect. In 1972, the American Hospital Association responded to consumer pressure and adopted "A Patient's Bill of Rights," which pertains primarily to hospitals but involves physicians with several responsibilities to patients ("Statement," 1973). A physician who subscribes to the bill of rights is obligated, with limited exceptions, to keep the hospitalized patient informed of diagnosis, treatment, and prognosis, to instruct the patient fully regarding possible consequences and alternatives before obtaining consent for medical procedures, to honor a patient's refusal to consent to treatment to the extent permitted by law, to protect the patient's right to confidentiality and privacy from physicians and staff not involved in his or her case, and to instruct the patient of his or her care requirements after discharge. These standards represent a significant departure from the traditional paternalism prevailing in the patient–physician relationship.

Still, the Patient's Bill of Rights was generated by a professionally dominated group. On some issues, such as informed consent, it actually incorporates traditional paternalistic exception clauses that might be rejected by those emphasizing the rights of patients. Other bills of rights have been developed such as those for nursing home patients, the mentally retarded, children, and other vulnerable groups. It is not clear how the statements of these documents are to be sanctioned, since no mechanisms of enforcement are specified.

Conclusion

The difficulties that confront professional leaders, patients, surrogates, and public policymakers who undertake the establishment of ethical standards on new issues reflect the conflicts in fundamental values inherent in diverse views of medical ethics. The traditional professional ethics of physicians places great emphasis on the virtue of benevolence and the physician's responsibilities to serve the patient. This tradition honors the individuality of the patient–physician relationship, professional secrecy, and the physician's duty to promote the patient's welfare. In these and other matters, ethical formulations by physicians have been paternalistic, making the physician the dominant party in determining which action will best further both the physician's and the patient's interests. Codes prepared by interests outside the medical profession (including those written by religious and governmental bodies) have advanced other philosophical tenets as foundations for medical ethics. Some of these codes have focused on justice or equity in allocating resources. This has resulted in mounting ethical confusion as physicians become subject to competing ethical authorities with conflicting standards.

Responsibility for the development of ethical guidelines relative to the physician–patient relationship may be shifting from the physician to the society as a whole. In those contingencies not anticipated by accepted guidelines, the responsibility for ethical criteria rests partly with the individual physician, partly with patients, and partly with society's general ethical standards. Future success in the use of codes to control medical practice may well depend on an accommodation of the ethical norms of physicians with those of the larger society.

robert m. veatch (1995)