Medical Ethics, History of Europe: III. Nineteenth Century. B. Great Britain
III. NINETEENTH CENTURY. B. GREAT BRITAIN
Questions of medical ethics acquired heightened significance in nineteenth-century Great Britain. The reform of the medical profession and the growing prominence of medicine within public policy brought ethical and medico-legal issues into sharper focus. For the first time, medical ethics assumed codified form.
The period from the early sixteenth century to the close of the eighteenth saw the founding of medical colleges and societies in Britain, among them the Royal College of Physicians. But such bodies played only a minor part in imposing ethical codes upon the profession as a whole—or even suggesting them. The Royal College of Physicians and the Royal College of Surgeons possessed jurisdiction over one city, London. There was no centralized medical regulation over most of the nation. With few exceptions, it was only in the nineteenth century that medical ethics were written down, the watershed being the publication in 1803 of Thomas Percival's Medical Ethics; or, A Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons. Two circumstances provided impetus for codification, one intellectual, the other socioeconomic. Intellectually, the moral philosophy of the Scottish Enlightenment and the reawakening of religious conscience associated with Evangelicalism concentrated attention on man's (concern was almost wholly with males) duties to society. John Gregory, professor of medicine at Edinburgh, had published his Observations on the Duties of a Physician in 1770, and Rev. Thomas Gisborne, a friend of Percival, had included a section on obligations attending the calling of a physician in his An Enquiry into the Duties of Men in the Higher and Middle Classes of Society in Great Britain, Resulting from their Respective Stations, Professions and Employments (1794). Percival certainly drew on both in shaping his Medical Ethics, though it would be a mistake to assume that Percival was significantly concerned with academic philosophy. His handbook was first and foremost practical. It contained no discussion of any philosopher by name and did not refer to particular formal philosophical schools.
At the same time, the tremendous social transformations precipitated by the industrial revolution were posing exacting problems for medical practitioners. Newly emergent urban communities had severe medical needs but no deep-rooted traditions of professional service. In Britain's laissez-faire, free-market economy, doctors were tempted to adopt entrepreneurial attitudes, operating according to the law of "let the buyer beware." Moreover, new medical institutions were springing up, above all charity hospitals and dispensaries for the poor. Codes of practice governing the duties of doctors attached to these distinctive establishments needed to be formulated.
Thomas Percival (born in 1740) had studied medicine at Edinburgh. He became a senior and well-respected Manchester practitioner, and a leading light in the town's Literary and Philosophical Society. When a virulent intraprofessional feud flared up at the Manchester Infirmary in 1792—a sordid fracas concerning nepotistic appointments—he had been called in as a kind of peacemaker. His Medical Ethics arose from his musing on that unseemly rumpus. It was thus a work that spoke directly to the needs of its times. Percival set out some precepts, of a somewhat platitudinous nature, about the general duties and responsibilities of the physician to his patients, to society, and to his calling. Above all, he addressed himself in a direct manner to the tangible difficulties facing doctors in a commercial society.
High on Percival's list of priorities was the desire to secure harmony among practitioners and between the different grades of the profession. He addressed such questions as seniority and precedence, spelling out in detail the protocols of joint consultations. Though little interested in formal professional bodies, he was adamant that "medical men" should not compete against each other; instead they should cultivate, and be seen to cultivate, a comradely esprit de corps. Professional rivalries, naked jealousies, and controversies in public conducted through the medium of pamphlets would poison intraprofessional relations and ultimately work to the disadvantage of patients. Charging lower than normal fees, for instance, would deny a living to poorer brethren, and discourage the young from investing in a thorough medical education and training. A liberal profession could not be supported, Percival insisted, except as a "lucrative one."
Sentiments such as these give support to those, like Chauncey Leake and Ivan Waddington, who argue that Percival's Medical Ethics was misnamed, being in truth a work of "medical etiquette," primarily designed to bolster the collective status, dignity, and monopolistic power of the profession vis-à-vis the public. Percival certainly aimed to regulate "the official conduct and mutual intercourse of the faculty"; but it should not be forgotten that he added that this was to be accomplished "by precise and acknowledged principles of urbanity and rectitude"—that is, the unwritten but generally acknowledged code of gentlemanly behavior. In other words, he was concerned not with self-serving expediency but with humanitarianism, prudence, and honorable standards of virtuous conduct as understood by a gentleman.
Some American philosophers of medical ethics are inclined to see Percival as having written a work with strong foundations in academic ethical philosophies. It has, for example, been suggested that Percival and his successors may have drawn upon utilitarianism. There is little warrant for this reading in Percival himself. The great bulk of his text was concerned with resolving practical problems among medical men.
Percival upheld the ideal of the professional pyramid. Where wealth and density of population permitted a professional division of labor, the traditional hierarchical separation between physicians, surgeons, and apothecaries was to be maintained because it stimulated specialist skills. Yet physicians were not to lord it over the lesser "gentlemen of the faculty": in small communities, the humble apothecary was often the best expert on the circumstances of patients, and so his advice should be heeded.
Percival thus required courtesy among practitioners. A compassionate man, he insisted that the fears and feelings of the sick should be respected. Ever the realist, he acquiesced in the authority deriving from social status that the gentry were accustomed to wield. Wealthy patients would exercise the right to a second or third opinion: It was up to the doctors involved to manage such delicate circumstances with tact, preventing the dangers of "divide and rule." Likewise, though nostrums were an abomination, Percival judged that the astute physician would sometimes comply when a patient insisted on a worthless, but safe, favorite proprietary remedy.
With affluent patients, the one who paid the piper would evidently call the tune. But different rules must apply, Percival observed, when practitioners gave their services without charge. Charity patients in infirmaries could not expect to pick and choose among the physicians or to negotiate over treatments. Disobedient hospital patients must face dismissal. Likewise, it was permissible to experiment with new remedies or surgical procedures upon charity patients, so long as such innovations were attempted with due caution and humanity.
Prizing the close clinical relationship between practitioner and patient, Percival believed this depended primarily upon the character of the physician. The ideal practitioner was an academically educated, liberal gentleman who would combine "tenderness with steadiness," and "condescension with authority," displaying proper composure, dignity, tact, and courtesy. He must govern himself: be temperate, avoid intoxication, and take care to retire from practice before age eroded his powers and judgment. He must be civil to colleagues, benevolent toward patients. It was a paternalist ideal, entailing a gentlemanly noblesse oblige.
Percival's book became immensely influential in the United States, serving as the basis for the American Medical Association's (AMA) code of 1847. Though reprinted in 1849, it achieved less celebrity in Britain. This was not because it was superseded by any other more illustrious tome or rival ethical scheme. For subsequent works, like William Ogilvie Porter's Medical Science and Ethicks: An Introductory Lecture (1837) and Abraham Banks's Medical Etiquette (1839), largely echoed Percival's platitudes; and as late as 1878, Jukes de Styrap was still lifting phrases out of Percival in A Code of Medical Ethics. Rather, in contrast to that in the United States, the medical profession in nineteenth-century Britain seems to have felt little need for explicit ethical codifications.
The contrast is readily explained. In early-nineteenth-century America, no standard, universal, and accredited licensing procedures unambiguously demarcated orthodox practitioners from quacks and irregulars. Hence, when regulars banded together into state medical societies to enhance their prestige, the adoption of a code of ethics was of immense significance as a conspicuous shibboleth. In Britain, by contrast, licensing was already well entrenched; since 1815, the Apothecaries Act had stipulated nationwide minimum qualifications for practice as an apothecary or general practitioner. Thus, in Britain, regular doctors did not need written codes of ethics to prove their standing in relation to irregulars. In Britain regulars were already adequately defined in contrast with quacks.
Nor did regulars need codes of medical ethics to affirm their personal bona fides. British practitioners were confident that they were, first and foremost, gentlemen. Gentility came from birth and breeding, education, wealth, contacts, manners, mien, and so forth—or at least from the capacity to create a show of such attributes. (Needless to say, most medical practitioners were not, in the literal sense, the sons of gentlemen; rather, they aspired to genteel status.) Gentlemanly behavior depended heavily upon notions of personal honor rather than upon formal ethical or religious principles. A written ethical code might have seemed to impugn a gentleman's honor, rather as the British prided themselves politically upon not having a formal written constitution. It is thus no surprise that the British medical profession was indifferent to collections of medical ethics. Neither the Royal College of Physicians nor the Royal College of Surgeons drew up an ethical code for its members.
From professors of forensic medicine, students learned a little about the rules governing evidence to be given in court. The Manchester Medical Ethical Association was formed in 1847, aiming to bind its members to a slate of regulations outlawing the marketing of nostrums and the giving of testimonials for patent medicines. And the British Medical Association—the newly formed society of general practitioners and family doctors—set up its own medical ethics committee in 1853. Over the next fifteen years, however, it signally failed actually to draw up a corpus of medical ethics. Despite such token activities, no comprehensive manifesto of ethical principles was codified in Britain that was binding upon the profession as a whole.
Yet this is not to say that the profession was indifferent to ethics. As was vehemently argued in Thomas Beddoes's A Letter to the Right Honourable Sir Joseph Banks … on the Causes and Removal of the Prevailing Discontents, Imperfections, and Abuses, in Medicine (1808) and in countless subsequent works, it was at bottom ethical commitments that distinguished honorable practice from quackery (although, Beddoes implied, all too often eminent regulars disgraced their vocation by unprincipled practices). And, of course, ethical dilemmas often arose that urgently needed resolution. A formal mechanism for upholding ethical standards was constituted in 1858 as a consequence of the establishment of the Medical Register, a public roll of all duly licensed practitioners. The body appointed to act as guardian of the register was the General Council of Medical Education and Registration of the United Kingdom, commonly known as the General Medical Council (GMC). The GMC was to admit properly qualified practitioners to the register, and to delete those whose conduct was professionally inadmissible—for example, those who had been convicted of a crime or who had been judged guilty of infamous professional conduct (such as adultery with a patient or vilification of colleagues). Sitting in camera, the GMC thus served as a sort of moral inquisition for the profession.
But what constituted "unprofessional conduct"? For most of the Victorian age, practitioners were held to less taxing standards than have generally been enforced in twentieth-century Britain. Considerable leeway was still permitted to engage in commercial and entrepreneurial activities. It was not unknown for eminent Victorian physicians to puff proprietary preparations with impunity, or to lend their names to extravagant publicity for spas, clinics, and balneological establishments. Such respectable medical organs as the British Medical Journal and Lancet published advertisements every week for nostrums, health foods, and medical institutions of doubtful probity (for example, socalled nursing homes that probably served as abortion clinics).
Nevertheless, the profession grew increasingly mindful of the fact that, in an age priding itself upon public probity, respectability, and heightened moral sensibilities, doctors had to be seen as above scandal. Trying situations easily occurred. For example, from the 1840s, thanks in part to the development of anesthetics, the scope for surgical intervention rapidly grew. Enterprising gynecologists and surgeons newly claimed to be able to treat a wide range of women's ailments, physical and psychosexual, through hysterectomy, ovariotomy, and similar operations upon the reproductive system. In the first flush of enthusiasm, some practitioners leapt in before the ethical implications had been adequately debated and resolved: Was proper informed consent being obtained for such operations? In the case of the removal of a womb, was it desirable to obtain the consent of the husband as well as of the patient? In the absence of diseased organs, was it permissible to perform operations for purely preventive or psychological reasons? Anxiety that the good name of the profession was being jeopardized by overenthusiastic intervention led to the expulsion, in the 1860s, of Isaac Baker Brown, a prominent advocate of clitoridectomy and similar surgery, from the Obstetrical Society (though he was disciplined not for the operations he performed but for the self-seeking manner in which he publicized them). Greater caution was subsequently exercised.
Whenever possible, the medical profession aimed to police its operations discreetly, retaining in its own hands the right to set moral standards. Thus, in ethically sensitive areas such as abortion, it was contended that termination of pregnancy was essentially a matter of clinical judgment in the individual case; in the last resort, only the personal physician was in a position to decide. Likewise, when legislation was proposed to control the sale of dangerous drugs, the profession was successful in safeguarding the right to supply narcotics on prescription.
In other medical spheres, however, ethical controversies arose that could not be kept within the circuit of professional discretion. This was because the Victorian age witnessed an unprecedented expansion of doctors' involvement in implementing state policy. For example, by 1900 new lunacy laws resulted in the compulsory confinement of nearly 100,000 mental patients. All had to be certified by due medical authorization. This created ethical predicaments for doctors that could not be resolved within Percival's notion of a tacit contract between physician and patient. Certain doctors, like the distinguished early Victorian psychiatrist John Conolly, warned of what a later generation was to call "psychiatric abuse": Some patients, Conolly feared, were being stripped of their rights and liberty not because they were sick but because they were nuisances or were merely eccentric.
It was in public health that the greatest ethical dilemmas arose. Before 1800, Great Britain had lacked the apparatus of medical police controls already in place on the Continent. This changed. The success of Jenner's variolation techniques (giving a dose of cowpox to create immunity against smallpox) led Parliament to make smallpox vaccination compulsory in 1853. Poor Law doctors—doctors appointed under the New Poor Law (1834) to tend to the parish poor, particularly those confined to workhouses—were to act as state agents in enforcing the legislation. Resistance and protests grew common during the next half-century, condemning compulsory vaccination as an iniquitous annulment of natural liberties and condemning doctors for serving as the lackeys of a coercive state.
A similar crisis arose in 1864 with the Contagious Diseases Acts. These sanctioned, under certain circumstances, medical inspection for signs of venereal disease of women detained by the police under suspicion of prostitution. Once again, opponents accused medical men of prostituting their art in the service of a corrupt state, and feminists argued that the acts were designed to provide disease-free vice for men. Around the same time, antivivisection agitators began accusing medical experimenters and scientists of inflicting cruelty upon dumb and defenseless experimental animals. The widening circle of medicine began to raise medical-ethical issues never dreamed of in the innocent days of Percival's Medical Ethics. Just before World War I these dilemmas came to a head when convicted suffragettes (militant feminists) went on a hunger strike, and prison doctors were instructed to administer forced feeding. Did their duty lie to society or to the prisoner (hardly a patient in the normal sense of the term, one who voluntarily seeks medical aid)?
In a characteristically British manner, professional bodies judged that the decision must be left to the doctor's scruples. The ingrained habits of individuality, specific to English liberal politics, and the cult of the gentleman that formed the unspoken code of male elites in all contemporary European societies meant that in professional eyes and, to a large degree, equally in the public mind the ethical dilemmas raised by medicine were best handled not by the law courts, jurists, academic philosophers, or Parliament but by the integrity of private practitioners following clinical judgment and their own consciences. These precepts, for better or worse, left a potent legacy to twentieth-century Britain. They certainly offered great latitude to the medical profession while placing heavy burdens upon its shoulders. Radical critics of the professions and their ideologies have contended, surely correctly, that the formulation of medical ethics enhanced the status and exalted the independence of the nineteenth-century doctors. How far this process helped to protect the public is more difficult to judge.
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