Medical Codes and Oaths: II. Ethical Analysis

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II. ETHICAL ANALYSIS

The following is a revision and update of the first-edition article "Codes of Medical Ethics: Ethical Analysis" by the same author.

Codes, oaths, and prayers of medical ethics have emerged over the centuries from disparate sources, representing disparate societies, time periods, organizations, and perspectives. It is not surprising that they differ significantly in style and content. This article will examine systemically the ethical content of this divergent collection of documents from the earliest to contemporary times. In the Appendix, the reader will find the texts of codes and additional bibliography of codes and commentaries on codes for ethics of the medical and other health professions.

Ethical analysis of the codes of medical ethics creates problems. Such codes are not fully developed, systemic theories of medical ethics. On the other hand, the codes, at least the modern ones, are normally the product of much discussion, debate, and review. These codes, along with the historical documents that have had lasting significance, can reasonably be expected to reflect the basic ethical views of the organizations that have endorsed them.

When one turns to the substance of the codes, especially the codes written by physicians, one can identify what might be called a central ethical obligation, a basic principle that provides the physician with a core moral stance for resolving ethical dilemmas. Striking features are the presence of contradictions among the codes and the controversial nature of these central ethics.

Hippocratic Oath

Modern Western medical ethics has reiterated the central ethic of the Hippocratic oath into the twentieth century. The core ethic of the Hippocratic oath is the physician's pledge to do what he or she thinks will benefit the patient. This is repeated twice in the oath, once as applied to matters of diet, and once when referring to visits to the homes of patients.

The principle that the physician's first obligation is to do what the individual physician thinks will benefit the sick person is picked up in the Declaration of Geneva, where the physician swears, "The health of my patient will be my first consideration," and in the International Code of Medical Ethics of the World Medical Association (WMA), which proclaims, "A physician shall owe his patients complete loyalty and all the resources of his science." Likewise, the postcommunist Russian oath has the physician pledge, in Hippocratic fashion, to work always for the patient's good (Solemn Oath of a Physician of Russia).

THE HIPPOCRATIC OATH'S INDIVIDUALISM. The first characteristic of the Hippocratic ethic is that it is individualistic; it concentrates only on the benefit to the individual patient. In contrast, classical utilitarian ethics of the tradition of Jeremy Bentham (1748–1832), John Stuart Mill (1806–1873), and G. E. Moore (1873–1958) would consider such a narrow focus on consequences for the patient to be ethically unjustified, unless it would serve the greater good of the greater number in the long run. They would consider benefits to all persons and to society as a whole. There is no evidence that the Hippocratic authors or their twentieth-century counterparts had such an indirect utilitarianism in mind. Rather, they seem to hold that the physician has a special ethical obligation to benefit his or her patient, independent of the net consequences for others who are not patients. The real test comes in cases in which the physician believes that one course will produce the most good in total, but another course will most benefit the patient. A physician who feels required to choose the course most beneficial to the patient is faithfully following the oath and rejecting the utilitarian alternative.

The American Medical Association (AMA), in its 1957 Principles of Medical Ethics, did not accept the Hippocratic individualism. It instructs the AMA physician that "the principle objective of the medical profession is to render service to humanity." The tenth principle made this interpretation unambiguous:

The honored ideals of the medical profession imply that the responsibilities of the physician extend not only to the individual, but also to society where these responsibilities deserve his interest and participation in activities which have the purpose of improving both the health and the well-being of the individual and the community.

This focus on the community continued in the major revision of 1980. The last principle of that version is, "A physician shall recognize a responsibility to participate in activities contributing to an improved community" (American Medical Association, 1989, p. ix).

Here the AMA is closer to the now-abandoned Soviet physicians' oath of 1971 than to the Oath of Hippocrates. The Soviet physician more boldly swore "to work conscientiously wherever the interests of society will require it" and "to conduct all my actions according to the principles of the Communistic morale, to always keep in mind the high calling of the Soviet physician, and the high responsibility I have to my people and to the Soviet government." By contrast, the postcommunist Russian oath reverts to the pure Hippocratic focus on the good of the individual patient, abandoning any reference to the interests of the community or state (Solemn Oath of a Physician of Russia). The Criteria for Medical Ethics of the Ministry of Health of the People's Republic of China (1989) are actually closer to the postcommunist Russian oath and its Hippocratic ancestors by focusing on the interests of the patient. It lacks any appeal to the duty of the physician to the community that is seen in the AMA and the Soviet oaths.

THE HIPPOCRATIC OATH'S PATERNALISM. The central ethic of the Hippocratic tradition is also paternalistic. The physician is to benefit his or her patient "according to my ability and judgement" (Edelstein, 1943, p. 3).

Addressing the meaning of the injunction to protect the patient from mischief and injustice, Edelstein concludes that the oath means that "the physician must protect his patient from the mischief and injustice which he may inflict upon himself if his diet is not properly chosen" (Edelstein, 1943, p. 24).

This paternalism is also seen in the provision of the Hippocratic oath that medical knowledge is to be kept secret and not disclosed to people outside the Hippocratic group. A similar provision is seen in a sixteenth-century Japanese medical code called the Seventeen Rules of Enjuin, which actually required that, if a successor trained in the School of Enjuin could not be found upon retirement or death, the medical books of the school had to be returned to the school.

Physicians, according to Percival (1740–1804) (who also shared in this Hippocratic paternalism), should study not only tenderness and steadiness but also "condescension and authority, as to inspire the minds of their patients with gratitude, respect, and confidence" (Leake, p. 71). The AMA principles of 1957 and the 1959 British Medical Association (BMA) codes held that medical confidences could be broken if, in the judgment of the physician, it was in the patient's interest for them to be broken.

THE HIPPOCRATIC OATH'S FOCUS ON CONSEQUENCES. Finally, one sees the controversy of the Hippocratic patient-benefiting ethic when it is contrasted with other theories that can be called nonconsequentialist, that is, ethical theories in which certain principles are taken to be simply inherently right-making or where certain claims are taken to be "inalienable rights." Holders of views in which there are certain characteristics of actions that make them inherently tend toward being right (other things being equal) or holders of the view that certain things, such as life, liberty, and the pursuit of happiness, are "inalienable rights" would have to reject the ethic of doing what one thinks will benefit the patient. At least they would reject patient benefit in cases where benefiting the patient will be at the expense of fulfilling prima facie duties or respecting basic rights of the patient.

There may be a paradox in the Hippocratic oath. The physician is to do what he or she thinks will benefit the patient but is not to give an abortive remedy or a deadly drug and is not to "use the knife, not even on sufferers from stone." What is the physician to do who believes that giving a deadly drug or an abortifacient remedy, or using the knife, will benefit the patient? Perhaps this apparent contradiction is resolved by the belief of the Pythagorean physician that such actions can never be beneficial to the patient. In that case, the oath simply spells out some rules that guide the physician in deciding what will be beneficial. More likely, however, these actions are seen as inherently wrong even if they might be of benefit. If so, then the Hippocratic ethic abandons its consequentialism, at least for these cases.

Codes Written by Groups Outside the Medical Profession

Many of the more recent codes written by governmental and religious groups have not shown these characteristics of individualism, paternalism, and consequentialism. The Nuremberg Code (1947), one of the first codes relevant to medical ethics emerging in international law, could have addressed the problem of abuse of human subjects in medical research by retreating to Hippocratic individualism, thus making all use of subjects for purposes of gaining knowledge immoral (because, by definition, doing something for the pursuit of general knowledge is not acting for the purpose of benefiting the patient). It did not. Instead it acknowledged the legitimacy of physician participation in efforts to benefit society by doing research on human subjects. It introduced protections for those subjects by abandoning the exclusive focus on consequences—on producing benefits and avoiding harms—and replacing it with an ethic that speaks in terms of duties and responsibilities, including the duty to ensure that the subjects give their informed consent.

Other codes coming from governmental and religious sources adopted the language of rights as a way of signaling their break with the professional medical ethical traditions that focus exclusively on consequences. This focus on rights is influenced heavily by the tradition of the liberal political philosophy of John Locke, Thomas Hobbes, Jean Jacques Rousseau, and the authors of the Bill of Rights of the United States Constitution. It is a moral tradition significantly different from that of the traditional, professionally written medical codes.

The focus on rights and duties includes an emphasis on the right to give informed and voluntary consent not only for research but for all clinical, medical treatments. Consent, grounded in the moral principle of autonomy and the legal notion of self-determination, is totally absent from the classical codes written by medical professional groups. The introduction of the perspective of rights and duties, and the underlying moral notion of respect for persons (including the principle of autonomy), signals a rejection of both traditional Hippocratic paternalism and consequentialism. It also provides a way of moving away from pure individualism, incorporating a more social ethic without lapsing into a social utilitarianism that would completely subordinate the individual to the aggregate social good.

The first healthcare association that used the language of rights was the International Council of Nurses' Code for Nurses (1973, reaffirmed 1989). Still using gender-specific language, it nevertheless signaled a revolution in the philosophical orientation of professional codes when it said, "Inherent in nursing is respect for life, dignity and rights of man." This use of "rights" language also appeared in the American Nurses' Association (ANA) code revision in 1976, when it proclaimed (with more gender-neutral language), "Each client has the moral right to determine what will be done with his/her person." By making self-determination of clients its first principle, the ANA announced it was the first organization of healthcare professionals to abandon Hippocratic paternalism and exclusive focus on consequences. However, ambivalence persists; after announcing that self-determination is its first principle, it says that "the nurse's primary commitment is to the health, welfare, and safety of the client" (American Nurses' Association, 1985, p. 6). At this juncture, the nursing profession seemed unable to decide whether to abandon Hippocratic paternalism in favor of respect for rights of self-determination or remain Hippocratic.

The AMA followed this pattern in its 1980 revision. It begins to use rights language saying, "A physician shall respect the rights of patients, of colleagues, and of other health professionals" (American Medical Association, 1989,p. ix). It commits the physician for the first time to deal honestly with patients, reversing the long-standing, more paternalistic approach in which physicians were expected to withhold information when they believed it might harm the patient. Yet, it still proclaims the Hippocratic notion that the AMA's ethical statements are developed "primarily for the benefit of the patient," and not, apparently, to protect the patient's rights.

Specific Ethical Injunctions

The strictures against abortion, euthanasia, and surgery in the Hippocratic oath are examples of specific injunctions that occur from time to time in the codes and oaths of medical and physician ethics. Code-by-code comparison of these injunctions reveals interesting differences. The conflict among the codes on the question of confidentiality is perhaps the most dramatic.

CONFIDENTIALITY. The Hippocratic injunction on breaking confidentiality is sometimes taken to forbid breaking medical confidences. The text is really much more ambiguous. It says, "Whatever I may see or hear in the course of treatment in regard to the life of men, which on no account one must speak abroad, I will keep to myself holding such things shameful to be spoken about." The individual physician, however, is left with the question of just which things he or she hears "on no account must be spoken abroad." Possibly physicians are to use the "patient-benefiting" criterion for deciding when breaking the confidence is appropriate. That was the explicit principle in the 1959 version of the BMA code, which said:

The complications of modern life sometimes create difficulties for the doctor in the application of this principle of confidentiality, and on certain occasions it may be necessary to acquiesce in some modification. Always, however, the overriding consideration must be the adoption of a line of conduct that will benefit the patient, or protect his interests.

The World Medical Association's International Code of Medical Ethics (1949, amended 1968 and 1983) and the Declaration of Geneva (1948, amended 1968 and 1983) both close any such patient-benefiting loophole in the confidentiality principle. They simply require "absolute secrecy," much as did the ancient Jewish Oath of Asaph. No exception is considered even in a case where the physician has learned that the patient is about to commit mass murder. The Ethical and Religious Directives for Catholic Health Facilities (1975) is almost as blunt. It requires that

professional secrecy must be carefully fulfilled not only as regards the information on the patient's charts and records but also as regards confidential matters learned in the exercise of professional duties.

In keeping with their more social commitment to the welfare of others as well as the patient, the now outdated 1957 American Medical Association Principles (1957, revised 1971), and the American Psychiatric Association's(1973), which were based on them, were quite explicit in providing three exceptions to the general principle of confidentiality:

A physician may not reveal the confidences entrusted to him in the course of medical attendance, or the deficiencies he may observe in the character of his patients, unless he is required to do so by law or unless it becomes necessary in order to protect the welfare of the individual or of the society.

Confidences could be broken not only when the physician thought it would benefit the patient but also when he or she thought it would benefit society or when it was required by law, for example, informing the police of a bullet wound incurred in a crime. The ethical problem of such broad exceptions, of course, is not only the paternalism of the patient-benefiting exclusion but also the potential subordination of the patient's interests and rights to the interests of the society.

The BMA was confronted by a particularly difficult case in which the physician disclosed to the parents of a sixteen-year-old that she was taking birth-control pills. He defended the breaking of the confidence on the grounds that he thought it was for her benefit. Since this was explicitly permitted by the BMA code at the time, the General Medical Council acquitted him of the charge of unprofessional conduct. After that case, the BMA in 1971 amended its confidentiality principle and became the first to recognize the patient's right to confidence in cases where the patient and the physician disagreed. The new position stated that "if, in the opinion of the doctor, disclosure of confidential information to a third party seems to be in the best medical interest of the patient, it is the doctor's duty to make every effort to allow the information to be given to the third party, but where the patient refuses, that refusal must be respected."

However, in the years that followed, the BMA's position seems to have reverted to a modified version of the old policy permitting disclosures "if it is in the patient's own interest that information should be disclosed but it is either impossible, or medically undesirable in the patient's own interest, to seek his consent" (British Medical Association, 1988, p. 21). The BMA also has added a provision permitting disclosure for social purposes when it is necessary to safeguard the national interest or when the doctor has an "overriding duty to society."

ABORTION. On the controversial subject of abortion, groups authoring codes have followed the ethical stances of their subcultures. The Hippocratic oath follows the Pythagorean prohibition on abortion, even though abortion was not considered unethical in the broader Greek culture (Edelstein,1943). In the Oath of Asaph, the early medieval Jewish medical initiate is instructed, "Do not prepare any potion that may cause a woman who has conceived in adultery to miscarry." The 1975 Ethical and Religious Directives for(U.S.) Catholic Health Facilities follow, consciously and precisely, a traditional, theological explanation of official church teaching, devoting seven of forty-three principles to the subject. Directly intended termination of pregnancy before viability is never permitted nor is the directly intended destruction of a viable fetus. Treatments not intended to terminate a pregnancy but which nonetheless have that effect are permitted, provided there is a proportionately serious pathological condition of the mother and the treatments cannot be safely postponed until after the fetus is viable.

When the cultural base of the group writing the code is very broad, the code is predictably less specific about the ethics of abortion. The Declaration of Geneva said, "I will maintain the utmost respect for human life from the time of conception," without directly prohibiting abortion. Its 1983 revision softened the position even further, changing "from the time of conception" to "from its beginning" (Declaration of Geneva, 1948, amended 1968 and 1983). The WMA's International Code in its draft, but not in its finally adopted form, stated, "Therapeutic abortion may only be performed if the conscience of the doctors and the national laws permit." The American Nurses' Association (ANA), which also represents individuals with a wide variety of viewpoints, similarly avoids direct comments. In its code, revised in 1968 and in effect prior to the 1976 revision, the ANA says that "the nurse's respect for the worth and dignity of the individual human being extends throughout the entire life cycle, from birth to death" (italics added). The implication may be that fetal life is not included. A 1966 statement approved by the ANA Board of Directors recognizes "the right of individuals and families to select and use such methods for family planning as are consistent with their own creeds and mores," again appealing to individual conscience. Is the combined implication a toleration of the nurse's participation in abortion?

EUTHANASIA. An explicit obligation to preserve life is strikingly absent from the codes of ethics, both professional and public. In light of a widely held view that the duty, or one of the duties, of the physician is to preserve life, one would expect to find this duty emphasized. The only explicit, well-known reference is the weak formulation in the International Code (1949, amended 1968 and 1983), which says that "a physician shall always bear in mind the obligation of preserving human life." This obligation to "bear in mind" rather than explicitly attempt to preserve life is a very soft injunction, especially when combined with the patient-benefiting principle the code emphasizes.

Proscribing active killing is much more common in the codes, as might be expected from the general ethical prohibition on active killing, even for mercy, in many cultures and subcultures. The Hippocratic oath's formula is, "I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect." Interpretation of this prohibition is controversial. Some take it to forbid any criminal, malevolent homicide. What seems more likely, however, is a prohibition against merciful killing or assisting in suicide. While suicide, especially in the face of medical suffering, was not uncommon in ancient society, it was forbidden by the Pythagorean cult. This fact is cited by Edelstein in his defense of the hypothesis that the Hippocratic oath is a Pythagorean document (1943). According to the Caraka Samhita, acts "causing another's death" were one of the few things the Indian medical student should not do at his teacher's behest. The oath of Asaph instructs the Jewish medical student to "take heed that you not kill any man with a root decoction."

In the professionally written codes or those of the Catholic church, however, the prohibition against assisting in an act of killing has never been extended to apply to cooperating in withdrawal from treatment. The distinction between active killing and withdrawal of certain treatments is clear in the Ethical and Religious Directives for Catholic Health Facilities, according to which "the directly intended termination of any patient's life, even at his own request, is always morally wrong," and "euthanasia ('mercy killing') in all its forms is forbidden." The directives go on, however, to say that while "failure to supply the ordinary means of preserving life is equivalent to euthanasia … neither the physician nor the patient is obliged to use extraordinary means." Nor is it considered euthanasia "to give a dying person sedatives or analgesics for the alleviation of pain, when such a measure is judged necessary, even though they may deprive the patient of the use of reason, or shorten his life."

The AMA states in its Judicial Council Opinions that "the physician should not intentionally cause death" (American Medical Association, 1989, p. 13). At the same time, it acknowledges the legitimacy of forgoing life-sustaining treatment in accord with the preferences of the patient or surrogate. The postcommunist Russian oath, following the original Hippocratic language, commits the Russian physician never to give a deadly drug.

The distinction between active killing and forgoing treatment is made clearer when rights language is used, as in A Patient's Bill of Rights (1973), written under the auspices of the American Hospital Association. That document proclaims that "the patient has the right to refuse treatment to the extent permitted by law," presumably even if the result will be the death of the patient. However, there is clearly no corresponding right to drugs that will actively hasten death.

TRUTH-TELLING. One conspicuous conflict between the patient-benefiting principle and the more deontological ethical theories is over the question of what one ought to tell a dying patient. Historically, many of the professional codes are simply silent, presumably expecting the patient-benefiting principle to apply. The Indian oath of the Caraka Samhita is explicit: "Even knowing that the patient's span of life has come to its close, it shall not be mentioned by thee there, where if so done, it would cause shock to the patient or to others." The 1847 version of the AMA code instructs: "A physician should not be forward to make gloomy prognostications … but he should not fail, on proper occasions, to give to the friends of the patient timely notice of danger, when it really occurs; and even to the patient himself, if absolutely necessary." The violation of confidentiality in communicating to family or friends before informing patients either is not noticed or is justified on patient-benefiting grounds. Using the patient-benefiting principle as a basis for withholding the truth is traditional in professional physician ethics. The 1847 code makes the grounding explicit: "It is, therefore, a sacred duty … to avoid all things [that] have a tendency to discourage the patient and to depress his spirits."

The latent paternalism that justifies withholding information from patients for their own good is retained even in the period after 1980 when the AMA principles themselves pledge unqualified honesty. In the AMA Council on Ethical and Judicial Affairs' interpretation, an exception can be made to the requirement of informed consent "when risk-disclosure poses such a serious psychological threat of detriment to the patient as to be medically contraindicated" (American Medical Association, 1989, p. 32).

Even the authors of "A Patient's Bill of Rights" seem to yield to the paternalistic patient-benefiting principle when it conflicts with the patient's right to know. The bill first states that "the patient has the right to obtain from his physician complete current information concerning his diagnosis, treatment, and prognosis in terms the patient can be reasonably expected to understand." But it then qualifies this by stating, "When it is not medically advisable to give such information to the patient, the information should be made available to the appropriate person in his behalf." The potential conflicts of such an exception with the right to privacy or the right to receive information necessary for informed consent are not discussed. By contrast, U.S. courts and many codes generated outside the Hippocratic tradition insist that information be adequate for the patient to make a self-determining choice, even if that information is potentially upsetting.

JUSTICE IN DELIVERING HEALTHCARE. Many of the codes of physician and other medical ethics have some reference to the duty to deliver healthcare justly or equitably. The Hippocratic oath uses a term, adiki'e, often translated into English as "justice," but it really means "wrongdoing" more generally; it does not refer to equality of treatment or equitable distribution of benefits. The statement in the Hippocratic oath that physicians must abstain from sexual relations with males and females, free and slave, during a medical visit is as close as the text comes to a pledge of equal treatment.

The ancient Chinese medical ethical codes are much more far-reaching in emphasizing equal treatment of rich and poor. The commandments written by Chen Shi-Kung, a seventeenth-century physician, include the explicit commitment that "physicians should be ever ready to respond to any calls of patients, high or low, rich or poor."

Equality of access seems generally recognized as an ideal in many modern codes even if it is absent in the Hippocratic original. The twentieth-century Declaration of Geneva holds forth this ideal: "I will not permit considerations of religion, nationality, race, party politics, or social standing to intervene between my duty and my patient." The American Nurses' Association code declares, "The nurse provides services with respect for the dignity of man, unrestricted by considerations of nationality, race, creed, color, or status." The AMA recognizes that society must make decisions regarding the allocation of limited healthcare resources and urges that they be allocated on the basis of "fair, socially acceptable, and humane criteria." At the same time, it emphasizes that the physician's duty is "to do all that he can for the benefit of his individual patient" (American Medical Association, 1989, p. 3). The postcommunist Russian oath, by contrast, pledges never to deny medical assistance to anybody and to provide care with equal diligence to patients regardless of means or national or religious affiliation.

The Ethics of Professional Relations

In contrast with the lay or public codes or bills of rights, virtually all professional codes devote significant attention to relationships among professionals. The Hippocratic oath begins with a covenant by which the new physician pledges "to hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to take them this art—if they desire to learn it—without fee and covenant." It includes a pledge to keep secrets, much as any initiation ritual into a cult might.

The longest of the three sections of the AMA code of 1847 is devoted to "the duties of physicians to each other and to the profession at large." Since many of the codes emerged at a point historically when the profession was separating itself from others claiming to offer treatments and cures, there is often, even to modern times, strong language forbidding association with those not properly members of the group. The American Osteopathic Association, for instance, requires that a physician "shall practice in accordance with the body of systemized knowledge related to the healing arts and shall avoid professional association with individuals or organizations which do not practice or conduct organization affairs in accordance with such knowledge."

In terms of the sociology of the professions, it has been suggested that restraints on advertising, rules structuring referral of patients, instruction on the ways of handling an incompetent member of the profession, or exclusion of those not properly initiated into the profession have important functions in maintaining the professional monopoly. Apart from their role in protecting professional interests, however, it is also pertinent to analyze them as sets of ethical obligations.

Three different kinds of ethical arguments may underlie the detailed formulations of professional obligations to other professionals. First, such duties to one's colleagues may be defended on what could be called "universal" grounds. That would be the case if the ethical principles claimed as the foundation of such intraprofessional obligations are principles generally recognized by all persons. For instance, the AMA code of 1847 states detailed rules regarding professional consultation prohibiting "exclusion from fellowship" of duly licensed practitioners and requiring punctuality in visits of physicians when they hold consultations as well as secrecy and confidentiality so that the patient will not be aware of consultants' disagreements. These standards for consultation are defended on the grounds that "the good of the patient is the sole object in view." Although it is not generally argued, there is a presumption that rational patients should accept this principle. We have seen, however, that the principle of patient benefit is quite controversial when put up against competing ethical principles.

A second foundation for intraprofessional duties might be a special ethic for a special group, which nonmembers would not be expected to share or even understand. This would be the case, for example, if the profession is viewed as a kind of club or fraternity that invents its own norms and applies them only to its own members. The ethic of a profession is in part the ethic of fraternal loyalty, of special obligation to one's adopted brothers. The professional obligation may be seen deriving from the professional nexus rather than from some more universal source. It is a special ethic of a special cult.

The ethic of the AMA's 1847 code, like the ethic of the code written by Percival, is an ethic of dignity and honor among gentlemen: "There is no profession, from the members of which greater purity of character and a higher standard of moral excellence are required, than the medical." The discussion of duties of physicians to each other begins with the admonition that "every individual, entering the profession, as he becomes thereby entitled to all its privileges and immunities, incurs an obligation to exert his best abilities to maintain its dignity and honor, to exalt its standing, and to extend the bound of its usefulness." The text goes on to entreat the physician to avoid "all contumelious and sarcastic remarks relative to the faculty, as a body; and while by unwearied diligence, he resorts to every honorable means of enriching the science, he should entertain a due respect for his seniors, who have, by their labors, brought it to the elevated condition in which he finds it."

This gentlemanly ethic of honor and purity (the Hippocratic phrase is "purity and holiness") gives rise to special ethical burdens for the medical profession that the layperson cannot be expected to grasp. Professional "courtesy" (gratuitous services for practitioners, their wives, and their children) should probably be understood in these terms. "Courtesy" is an ethical expectation for members of the brotherhood.

A third possible foundation confounds the two. It could be that professional duties are defended as being in the public interest (or in some other manner consistent with a more universal ethic), but that only members of the profession can be expected to understand this to be so. Advertising, for instance, could be attacked, as it is in the AMA's 1847 code, as "derogatory to the dignity of the profession," but it is defended as necessary to separate the profession from "the ordinary practices of empirics." The authors might well hold that it is really in the public interest that the separation be made, but also concede that only members of the profession could see the necessity of that separation.

If there are special ethical obligations for members of the profession that in principle cannot be recognized from outside the professional group, it follows that there are likely to be conflicts between the profession's formulation of its ethical obligation and the broader public's formulation. The issue is not the existence of different ethical responsibilities attaching to different roles, but rather a disagreement between the profession and the broader public over what constitutes the proper behavior of the professional in his or her specific professional role. Even if a profession agrees that it has a special duty to preserve life or limit advertising, it is still an open question whether the public wants physicians always to act on that norm. If the professional group holds that there is a special professional source of norms, then conflict is predictable.

A specific example of such conflict involves the ethics of advertising. Many professional codes, in the manner of the 1847 AMA code, prohibit or restrict advertising by members of the profession. The 1957 Principles of Medical Ethics of the AMA claim that "this principle protects the public from the advertiser and salesman of medical care by establishing an easily discernible and generally recognized distinction between him and the ethical physician." While such prohibitions on advertising might be seen as the behavior of a cartel restraining price competition, it is also possible that physicians really believe that they are engaged in a service that must not be peddled as a commodity. Whether the medical profession sees such advertising as unethical or not, the public may see restraint on advertising as unethical. At stake are not only two different perceptions of ways to maximize benefits to potential patients, but also two sources of ethical norms—one from within the professional nexus and the other from the broader society. In this regard, an important transition occurred when the committee responsible for the 1980 revision of the AMA principles acknowledged that increasingly the public will be determining the norms for moral conduct in the lay–professional relationship.

Conclusion

The codes, oaths, prayers, and bills of rights derive from disparate contexts, representing differing professional groups, public agencies, and private, lay organizations such as churches and patients' groups. It is not surprising that radically different ethical conclusions are reached and that they are based on radically different fundamental ethical theories and methods of ethical reasoning.

One critical problem faced by health professionals as well as laypeople is what ethical directives should be decisive when an individual professes identification with more than one group. A health professional may also be a member of a religious or cultural group that has an ethical framework relevant to the moral problems faced by the individual. For example, if the ANA position can be interpreted as endorsing the nurse's tolerance of a woman's right to choose abortion, what is the Catholic nurse to do, or what is a nurse who works in a Catholic health facility to do if he or she believes in the right of the individual to select methods for family planning? These conflicts for individuals who are simultaneously members of more than one group, each of which has authored a code, arise for many ethical issues in healthcare. Moreover, individuals may reach conclusions of conscience that fail to conform to any codes of ethics whether written by healthcare professions or by religious, cultural, or governmental groups. An active understanding of the ethical differences among these codes is needed to begin developing a response.

robert m. veatch (1995)

SEE ALSO: Abortion; Autonomy; Beneficence; Confidentiality; Competence; Human Dignity; Medical Ethics, History of; Principalism; Profession and Professional Ethics;Virtue and Character; and other Medical Codes and Oaths subentries

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