Medical Ethics: Past, Present and Future
Heather MacDougall, PhD, Associate Professor, Department of History, University of Waterloo
G. Ross Langley MD, FRCPC, MACP, FRCP(Edin), Emeritus Professor of Medicine, Dalhousie University
Antiquity, Ayurvedic, Chinese, Christian, Guilds, Hippocratic, Hippocratic Oath, Indian, Islam, Judaism, Plague
AMA, AMA Code of Ethics, American Medical Association, British Medical Association, Brownell, Canadian Medical Association, CMA Code of Ethics, Edinburgh, John Gregory, International Code of Medical Ethics, Isaac Hays, Manchester Infirmary, Nuremberg, Thomas Percival, Royal Commission on Health Services, Saskatchewan, World Medical Association
Bill C-43, Canada Health Act, Jacques Genest, Job actions, Ontario Medical Association, Royal Commission on Reproductive Technologies, Physicians Strike, Royal College 1929, Royal College and Bioethical Issues
Table of Contents
- Part 1: Laying the Foundations
- Part 2: Medical Professionalization and Ethics Codes
- Part 3: Modern Medicine and Ethical Issues
- Summary and Conclusions
- Highly Recommended Readings
- Reference Notes
From antiquity to the present, all societies have faced health challenges that prompted the formation of groups of healers and the development of codes of ethics to govern the treatments that they offered. As evolving entities, these codes reflected the social values and class structure of the society for which they were framed. Thus, understanding the historical evolution of codes of ethics from individual oaths that marked medical education and practice as a vocation during the pre-Christian era through prayers that demonstrated the transition to a religious avocation in Judaism, Islam and Christianity to the medieval European guilds that began the process of transforming medicine into a paid profession, we can see not only how western medical training and practice evolved but also how deeply rooted the lay and medical concerns about confidentiality, end-of-life treatment, abortion, the changing role of technology, the personal character of medical practitioners and the social status of medicine have always been.
With the rise of scientific experimentation in the 17th and 18th centuries, western medicine began to claim expertise and the right to self-regulation. New standards for professional behaviour were articulated first by John Gregory and then by Thomas Percival. Their works provided many American and Canadian doctors who studied in Edinburgh and London with the intellectual foundation from which to formulate formal codes of ethics when the American and Canadian medical associations were created in 1847 and 1867, respectively. Building on the belief that medicine was an altruistic calling, these codes helped to define practitioners’ behaviour and to create group identity. But like all previous codes, they were criticized by other healers and members of the public as efforts to constrain choice and limit competition in the medical marketplace.
As medical practice shifted from the home to the hospital during the 20th century, the existing codes of ethics were altered to reflect the impact of specialty training and the increasing role of the Canadian government in funding health services. Internationally, the discovery that German and Japanese doctors undertook heinous medical experiments on captives resulted in the World Medical Association drawing up an international code of ethics to prevent such activities in future.1 Although national granting agencies today have stringent requirements for human experimentation, current research in the biomedical field has opened new ethical challenges for medical education and practice. Likewise, for Canada and other western nations that have government-funded health programs, the allocation of resources and the adoption of new technologies and drug treatments contributed to the revision of the “CMA Code of Ethics” and the creation of “Medical Professionalism in the New Millennium: A Physician Charter” by an international committee.2 The purpose of this primer, then, is to show how each society has grappled with defining a code of ethics for its medical students and clinicians and to show why this is a never-ending task.
To start our discussion, we need to understand that each of the methods that were used to define ethical behaviour reflected the values and beliefs of the society for which it was designed. Oath taking was a sacred activity in Greek society. As part of the initiation rite for students studying with Hippocratic practitioners, the Hippocratic Oath therefore was intended to create group cohesion, shared values and common behaviour patterns. Or did the oath represent an initial attempt to define universal values in the physician-patient relationship? Do the oath and its modern successors still perform those functions today?
Other societies chose to regulate their healers through government decrees and sharp social distinctions between types of practitioners and their scope of practice. The ability to purchase medical assistance was usually confined to royalty, the aristocracy or the wealthy upper classes, and the middle class merchants, urban workers, farm labourers, peasants, serfs and the poor had to rely on home remedies, astrologers, bone-setters, barber-surgeons and the charity of academically trained practitioners. Although religious orders provided charity care starting in the early Christian era, this model of altruism contrasted with the medieval guilds, which appeared to provide care for a set fee. Was medicine therefore a trade? What ethical foundation now existed, and who would define it? Was it simply understood that Christian principles of benevolence and charity would prevail, or was a specific code of ethics required?
As a result of scientific advances in medical knowledge during the Renaissance and Enlightenment, medical training and practice gradually began to professionalize. With capitalism replacing feudalism, a new social dynamic emphasizing the individual rather than the community emerged, and medicine, like other activities, had to adjust to the new economic reality and its philosophical foundations, which were highlighted in the works of David Hume and Adam Smith. In the English-speaking world, this led to the development of codes of ethics that enabled the profession to govern itself by policing the behaviour of individual practitioners. Many commentators see these codes as paternalistic (and frequently misogynistic) expressions of self-interest designed primarily to protect doctors from external competition and oversight by lay people and governments. Others argue that the principal aspects of these codes hark back to the emphasis on good character, scientific knowledge, technical expertise and compassion found in the Hippocratic Oath. As we will see, both interpretations have significant validity and highlight the ongoing quest to define the ever-changing role of doctors.
Studying the history of the development and use of oaths and codes of ethics provides us with a means of understanding how other societies grappled with ethical issues. But to do so requires an appreciation of the social, cultural, attitudinal, economic and political differences between the 21st and all preceding centuries. This primer therefore is divided into three sections: “Laying the Foundations,” which examines early societies and their attempts to define medical training and practice; “Medical Professionalization and Ethics Codes,” which discusses the process of professionalization and how British and American codes of ethics affected Canadian doctors and their associations; and “Modern Medicine and Ethical Issues,” which looks at the rise of bioethics, the secularization of society, the role of government and the transformation of medical practice as a result of new technology, scientific innovation, multiculturalism and renewed public interest in self-help and non-traditional medicine. Like healers throughout the ages, it is vital that you examine your own beliefs, read the current “CMA Code of Ethics” (https://policybase.cma.ca/documents/policypdf/PD19-03.pdf) and discuss with colleagues, friends and patients the key role that ethics play in medical training and practice.
All societies face disease and death. Anthropological and historical records demonstrate that health practices based on magic, herbal lore and polytheistic beliefs flourished in the pre-Christian era. In Mesopotamia and Egypt, two of the greatest empires in antiquity, the dominant political regimes codified medical practice, outlined expected treatments and set levels of remuneration. For example, Mesopotamian records from the reign of Hammurabi (1726–1686 BCE) included instructions for physicians concerning fees for the treatment of nobles, commoners or slaves and punishments for failure, such as chopping off the practitioner’s hand if he caused the death of a notable. In contrast, if a slave died, the doctor was expected to purchase a replacement.
Basalt stele with Law Code of Hammurabi, king of Babylon.
The Law Code of Hammurabi is the emblem of the Mesopotamian civilization. This high basalt stele erected by the king of Babylon in the 18th century BC is a work of art, history and literature, and the most complete legal compendium of Antiquity, dating back to earlier than the Biblical laws. The principal scene depicted shows the king receiving his investiture from Shamash. Courtesy of the Louvre Museum, Paris.
Text of the Basalt stele
The text occupies most of the stele, constitutes the raison d'être of the monument. Remarkable for its legal content, this work is also an exceptional source of information about the society, religion, economy, and history of this period. Courtesy of the Louvre Museum, Paris.
Clay tablets from the library of Assurbanipal (668–627 BCE) revealed that disease interpretations in this society were largely omen-based, using divination based on inspection of the livers of sacrificed animals.3 This reflected the division of medical practice among three types of healers: seers, priests and physicians. The seers performed the divinations, the priests conducted incantations and exorcisms, and the physicians provided drugs, bandaging and limited surgery. Hierarchy existed, with a head physician directing care for the royal family and court doctors being required to swear an oath “of office and allegiance.”4
Cuneiform Tablet with Omen from the library of King Ashurbanipal (reigned 669-631 BC)
This tablet is the third of a series of twenty-four called shumma izbu concerning malformed newborn humans and animals, and their ominous significance. Everything in Mesopotamia was believed to be the result of divine action, and signs (omens) were used to interpret the will of the gods. Ancient letters reveal that deformities in human and animal births were taken very seriously at this time.
Tablets such as this are the scholarly textbooks of their day, consulted by the expert to determine the will of the gods. Courtesy of the British Museum, London.
Similar practices flourished in Egypt, where magic and religion combined with accumulated knowledge to create a medical hierarchy whose activities were divided among various body parts or diseases. In both Mesopotamian and Egyptian society, women healers were active members of the medical elite, With their male counterparts, these women provided care based on the belief that “health was associated with correct living, being at peace with the gods, spirits and the dead; illness was a matter of imbalance which could be restored to equilibrium by supplication, spells and rituals.”5 The beliefs and practices of these two societies illustrated links between religion, magic and empirical practices and also indicated how early state intervention in defining roles and responsibilities originated.
Egyptian god, I-Em-Hetep or Imhotep
The Egyptian god, I-Em-Hetep or Imhotep, is the earliest known Egyptian deity of medicine and healing. Courtesy of the Wellcome Library London.
The roots of western medicine have traditionally been traced to ancient Greece and specifically to the teachings of the small medical group on the island of Cos: the Hippocratics. According to noted historian Roy Porter, “The significance of Hippocratic medicine was twofold: it carved out a lofty role for the selfless physician which would serve as a lasting model for professional integrity and conduct, and it taught that understanding of sickness required understanding of nature.”6 This combination demonstrated the ability of Hippocrates and his disciples to separate medical observation from religion and magic and to shift the focus from class-based medical care to selfless service of individual patients.
This statue of Hippocrates is located on the island of Cos. Courtesy of the Royal Society of Medicine and is a copy of Figure 5 from an article by Dr. Alex Sakula in the Journal of the Royal Society of Medicine In search of Hippocrates: a visit to Cos: 1984;Volume 77: (August) pp. 682-8.
Available online at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1440126
To differentiate themselves from their competitors, such as exorcists, religious healers, root-cutters, folk healers and iatroi (non-Hippocratic healers),7 Hippocratic physicians are thought to have sworn the Hippocratic Oath. The origins of this oath are unknown, and it is unlikely to have been written by Hippocrates himself, but its content reveals not only this cult’s understanding that observation and patient treatment had to be conducted in an ethical framework but also that their work affected society at large.
As this translation by Leon Kass8 demonstrates, the Hippocratic Oath unites Greek morality and medical craft in a way that speaks across the two millennia since it was devised.
TABLE 1: THE HIPPOCRATIC OATH
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant.
To hold the one 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, to regard his offspring as equal to my brothers in male lineage and to teach them this art — if they desire to learn it — without fee and covenant; to give a share of precepts and oral instruction and all other learning to my sons and to the sons of him who instructed me and to pupils who have signed the covenant and taken an oath according to the medical law, but to no one else.
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.
I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will withdraw in favour of such men as are engaged in this work.
Into whatever houses I may enter, I will come for the benefit of the sick, remaining clear of all voluntary injustice and of other mischief and of sexual deeds upon bodies of females and males, be they free or slave.
Things I may see or hear in the course of treatment or even outside of treatment regarding the life of human beings, things which one should never divulge outside, I will keep to myself holding such things unutterable [or “shameful to be spoken”].
If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honoured with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.
To classical scholars, the Hippocratic Oath represents the interplay of transgenerational knowledge transfer as well as the Greek reverence for téchne (knowledge, craft) and concern for dóxa (reputation).9 The student is promising the gods that he will regard his teachers as parents and provide for them and their children as he would his own. He will teach his master’s children and his own as well as pupils who also swear to this covenant, but not others, to maintain the specialized knowledge that separates Hippocratics from their competitors and those who have not sworn the oath.10
The ethical components of the oath reflect Greek society with its emphasis on public perception of the healer’s téchne. He was to use his knowledge and craft “in a pure and holy way” to succour his patients and “keep them from harm and injustice.” The prohibitions against euthanasia, abortion, cutting for stone, sexual misconduct and breaking patient confidentiality signal the types of problems that practitioners faced. They also indicate the behaviour that was expected of a student of the art of Hippocratic medicine and his commitment to personal and professional good conduct.11
But did Hippocratic practitioners live up to this oath in terms of pursuing their avocation? The limited information available in the works of Greek philosophers such as Plato, Aristotle, the Stoics and the Epicureans does not suggest a universal duty to care. Plato noted that “citizen physicians treated citizens, while their assistants cared for slaves.”12 No formal medical profession with licensing or government regulation existed in the ancient world, and the Hippocratic cult was restricted to “sons of Asklepios.”13 But as Roy Porter noted: “The Oath foreshadowed the western paradigm of a profession (one who professes an oath) as a morally self-regulating discipline among those sharing craft knowledge and committed to serving others.”14
Ancient India and China also produced medical teachings and practices that were codified and passed from master to student. Written in Sanskrit, the canonical texts of Ayurvedic medicine, the Charaka Samhita and the Susruta Samhita, date from the early Christian era but claim to represent teachings from the distant past. They provide extensive information on disease causation, treatment, surgical techniques and materia medica, as well as incantations (mantras), omens and injunctions about physicians’ behaviour.
Page from Ayurvedic Textbook
A page of text from the Sushruta samhita, an ayurvedic textbook, on various surgical procedures and surgical instruments. The text presents itself as the teachings of Dhanvantari, King of Kasi (Benares) to his pupil Susruta and is said to be by Susruta. Courtesy of Wellcome, Library London.
The Charaka Samhita also had an oath of initiation similar to the Hippocratic Oath, but there were some differences in India:
A pupil in Ayurvedic medicine had to vow to be celibate, to speak the truth, to adhere to a vegetarian diet, to be free of envy, and never to carry weapons. He was to obey his master and pledge himself to the relief of his patients, never abandoning or taking sexual advantage of them. He was not to treat enemies of the king or wicked people, and had to desist from treating women unattended by their husbands or guardians. The student had to visit the patient’s home properly chaperoned, and respect the confidentiality of all privileged information pertaining to the patient and his or her household.15
As taboos against treating people outside one’s social class intensified, the practices of Brahmin class vaidyas (good physicians) were limited to their own caste to protect their ritual purity. For other castes, home remedies, folk healers, astrology and religious faith provided succour during periods of pestilence, famine and other natural disasters. But Hindu principles of “respect for all life and the virtues of honesty, generosity, and hospitality” provided a firm ethical foundation for medical practice.16
The Medicine Budda
The Medicine Buddha, Bhaishajyaguru, with his right hand in the earth-touching position. His left hand, in a meditation gesture, holds a lapis lazuli bowl containing three pieces of myrobalan fruit (a species of plum), considered to have medicinal properties. To his right a miniature form of the deity, Green Tara, is depicted in a roundel. Below is Padmasambhava, who formally introduced Buddhism from India to Tibet. His two female consorts, Mandarava and Yeshe Tsogyal, flank him on either side. The Medicine Buddha sutras emphasise the value of visualising the Medicine Buddha and chanting the appropriate text, to promote the healing of body, speech and mind. Late 18th century. Courtesy of Wellcome, Library London.
Traditional Chinese medicine has a similar history and class component. Peasants received health care from folk or religious healers because they believed that demons or unhappy ancestors were the source of disease. Middle and upper class patients and the imperial court and bureaucracy were treated by learned practitioners who had been trained in the core texts: The Yellow Emperor’s Inner Canon of Medicine, the Divine Husbandman’s Materia Medica, the Canon of Problems and the Treatise on Cold-Damage Disorders. Like the Greeks, Chinese teachings stressed “the conviction that the body represents a microcosm of Nature and society” and that “health is dependent on the maintenance of internal bodily equilibrium, and also of harmony between the body, the environment, and the larger order of things.”17 But unlike the Greeks, Chinese medical theory emphasizes relations rather than natural principles. Thus, qi, which is energy, is affected by yin and yang forces that determine the diagnosis, prognosis and treatment to be prescribed.
Over the centuries, several different types of healers emerged in addition to the quacks, shamans, priests, masseurs and midwives who cared for the common folk. Women were prohibited from medical training except in Korea, but they became midwives and wet-nurses to the aristocracy since male doctors were unable to touch female patients according to examination protocol and hence did not perform obstetrics. Instead, trained practitioners included ruyi, or Confucian physicians, who were scholarly gentlemen philanthropists who were to treat the poor gratis, and shiyi, or “hereditary physicians,” who came from medical families who either specialized in a specific health problem or were famous for a specific cure. The latter might be considered equivalent to family physicians if they were paid by an annual retainer from their wealthy patients. As Roy Porter notes, however, neither these practitioners nor their counterparts who took the examinations to become imperial medical officers had high status or constituted “an organized corps of professional physicians in the modern western sense,”18 in part because all Chinese male heads of families were expected to care for their own families and it took generations to develop a distinct professional practice. This slow evolution also occurred without state support for the creation of a distinct professional group as occurred in western Europe during the Renaissance.19
However, the Chinese state recognized the need for health care and in the ninth century took over the hospices and infirmaries that Buddhist monks had created when they first arrived in China centuries earlier. During the Song and Yuan dynasties, charitable pharmacies and clinics were created, and after imperial support diminished in the 17th century, private charities appeared. Chinese medicine thus reflected the belief system and social structure of the society in which it was practised and differed from western medicine in its continued emphasis on holism rather than the mind-body duality of Cartesian western thought.20 Both Ayurvedic medicine and traditional Chinese medicine were systems that included book learning and apprenticeship designed to produce practitioners who were knowledgeable, competent and discreet.21 In Albert Jonsen’s view, “in the East, medical morality remained a deontology, rooted in religious and philosophical beliefs, and a decorum of polite and gracious behaviours.”22
The Roman conquest of Greece resulted in Greek doctors going to Rome to serve the wealthy, the military and the state. Ultimately, Greek medicine dispersed throughout the Roman Empire, and in the writing of Scribonius Largus (c. AD 1–50), a physician who went to Britain with the Emperor Claudius in AD 43, there is the first extant reference to medical ethics and the Hippocratic Oath.23
But the greatest synthesizer of the Hippocratic corpus and the leading physician of his day, Galen (AD 129–c. 216), overshadowed his contemporaries and set medical training and medical knowledge on a path that stressed its foundation in philosophy, principled behaviour, scientific experiment and dissection. According to Galen, good physicians had to study logic, physics (the science of nature) and ethics. They also should “practice for the love of mankind” but accept appropriate fame and rewards. These rewards depended on achieving the patient’s trust, which required “a punctilious bedside manner,” careful explanation of signs and symptoms, and a masterful prognosis based on “experience, observation and logic.”24
Scribonius Largus Text
Title page from: Compositiones medicae by: Scribonius Largus Published: Typis Pauli Frambotti Bibliopole Patavii 1655.
No bust of Galen has survived from antiquity. The only ancient representation of him is to be found in the so-called Juliana Anacia Manuscript written in the year 487. This portrait appears in Folio 3 greatly deteriorated. Mr. T. L. Poulton, artist at University College has reproduced the original line by line. Courtesy of Wellcome Library, London.
Rome did not develop medical schools, and students studied with specific teachers whose homes served as treatment centres for their wealthy patients. The poor went to shrines, and many others turned to self-help manuals such as Celsus’ On Medicine, folk healers, bodybuilders, “wise women,” root-gatherers and hucksters.
CELSUS, A. Cornelius
Engraving: portrait of Celsus; by J. van der Spyk, Aulus Cornelius Celsus was a Roman physician. His De Medicina is considered one of the best sources on Alexandrian medical knowledge. Courtesy of Wellcome Library, London.
Women were allowed to be midwives and nurses, and Galen and other writers commented favourably on their abilities. But new diseases appeared as the legions returned bringing smallpox from Mesopotamia; both it and bubonic plague spread around the Mediterranean. Although the army created hospital buildings and excellent sanitary facilities were built in Rome and other centres, disease causation was still seen by authorities as a supernatural phenomenon, requiring penitence and sacrifice to propitiate the offended gods. In contrast, “latter-day Hippocratics continued to emphasize individual susceptibility and bad air (miasma), and stressed dietetics.” And even Galen, who stressed individual constitutional problems, used dream prognostication, bird divination and amulets in his treatment regimen.25 These actions demonstrate the way in which Galen and his contemporaries were products of their society and illustrate the importance of understanding customs and behaviour from the perspective of the society in which they occur. Roy Porter summarizes the importance of Greek and Roman medicine by stating that it “laid solid foundations for learned medicine, including the naturalistic notion of disease as part of cosmic order, and the idea of the human body as regulated by a constitution, intelligible to experience and reason. It created the ideal of the union of science, philosophy and practical medicine in the learned physician, who would be a personal attendant of the patient rather than a medicine-man interceding with the gods or a functionary working for the state.”26
Celsus Book “De Medicina”
De Medicina, published by Johann Elzevier Leyden in 1657. De Medicina, is Celsus only extant work and the only surviving section of a much larger encyclopedia. Courtesy of Wellcome Library, London.
But it did not establish a medical profession that influenced government policy and dominated the health care system.
As the Roman Empire disintegrated, the knowledge so carefully developed along with the expertise of leading practitioners disappeared in the West as early Christianity, Judaism and Islam became the custodians of Hellenic and Roman medical knowledge. The gradual development of Christianity in the eastern and western sections of the former Roman Empire played a powerful role in the redefinition of medical practice even as medical knowledge derived from Greek and Latin writers declined in the West. Medical care became a tool to convert pagans as religious orders fought plagues in the third century and built hospices and leprosaria as part of a monastic commitment to community service. While there are very few references to the Hippocratic Oath in early Christian writings, an amended version that omits references to multiple gods and goddesses appeared before 1000 CE, but without formal university-based medical education, it is not clear who swore these oaths since medicine at this point was mainly provided by religious, not secular, practitioners.27 The growing strength of the Catholic Church and its use of Canon law to control medical practice by monks and nuns, however, contributed to the development of lay physicians and university medical courses based on the great texts that early Christian, Jewish and Arabic scholars had preserved during the five centuries of turmoil in the West.
Portrait of Rhazes (al-Razi) (AD 865 - 925) physician and alchemist who lived in Baghdad. Courtesy of Wellcome Library, London.
Book cover Razes
By: Rhazes. Published: Basle 1544.
Courtesy of Wellcome Library, London.
Portrait of Avicenna (980-1037).
Courtesy of Wellcome Library, London.
Other Islamic doctor-scholars, notably Ibn Sina (Avicenna 980–1037), also produced ethical treatises that demonstrated their knowledge of Hippocrates, Galen and Greek medicine as well as emphasizing the cultural constructs of their religious beliefs: “the ultimate power of God over life, death and healing and the obligation to care for the poor.”29
Muslim doctors were trained in the hospitals found in all the large cities, many of which were attached to mosques where students were taught the great works that had been translated into Arabic from Greek, Sanskrit and other languages. By the 10th century, many of the caliphates had established examinations to practise and licensure for public posts. This development would influence western Europe through Roger II and Frederick II of Sicily, when they began to reorganize medical education and practice in the 12th and 13th centuries.30
Being a monotheistic religion like Islam, Judaism placed a high value on human life, and many rabbis and scholars emphasized the role that Yahweh (God) played in providing healing either through his own action or human agents. Jewish scholars who produced the Persian and Babylonian Talmuds that commented on the Torah stressed the duties and honour associated with medical practice. The most famous rabbinical physician was Moses ben Maimon, or Maimonides (1135–1204), who was born and educated in Cordoba but settled in Cairo and became the Sultan Saladin’s personal physician.
Moses Maimonides (1135-1204) Photogravure
Courtesy of Wellcome Library, London.
Aphorismi medici by: Moses Maimonides
Page headed prologus from: Aphorismi medici by: Moses Maimonides, published: Bologna 1489. Courtesy of Wellcome Library, London.
Maimonides translated Hippocrates, Galen and Avicenna, and in his own writing he commented on the ethical requirements of good practice through a series of aphorisms and observations.31 He did not, however, write the prayer that has sometimes been part of North American codes of ethics. And the Catholic Church’s prohibition against consulting Jewish physicians meant that his ethical standards were not incorporated into western medicine even though they paralleled the Christian view of Jesus as a divine healer.32 Nevertheless, his work and that of other scholars in the Muslim Empire provided invaluable guidance for clinical practice, medical training and medical ethics as western Europe began to develop formal university-based medical education in the late Middle Ages.
As medical training moved into the universities of the Holy Roman Empire, it was formalized and gradually removed from Church control. In 1231, Frederick II, King of Sicily and Holy Roman Emperor (1194–1250), imposed regulations through the Constitution of Melfi, which required a five-year study of the “recognized books of Hippocrates and Galen” after study in the humanities, followed by a year of supervised practice before a medical degree would be granted. The medical faculty at Salerno conducted the examinations, and once qualified, doctors were expected to provide “free service to the poor and regular visits to the sick.”33 This decree started the process of professionalization by requiring students to complete a rigorous course, obtain practical experience and pass a stringent examination in order to be recognized as trustworthy practitioners.
Since relatively few men attended the medical faculties that sprang up in late medieval Europe, other bodies also participated in the development of medical knowledge and practice. Foremost among these were the medical guilds that appeared in Paris (c. 1200), Venice (1258) and Florence (1296). Like guilds for bakers, weavers and goldsmiths, the barber-surgeons created a hierarchical structure based on control by the masters, a corps of journeymen and indentured students. Although the rhetoric emphasized the paternal guidance that this apprenticeship program was expected to provide, for the men who founded these organizations, the purpose of the guild was to protect their livelihood while also performing charity work, introducing and maintaining public health regulations, preventing “negligence, malpractice and quackery,” and ensuring standard fees. In effect, members were striking a bargain with significant implications for medical ethics: “good service to city and citizens in return for a monopoly of practice and public prestige.”34 As Albert Jonsen points out, “[guild medicine] reinforced an often paradoxical duality between self-interest and altruism at the heart of medical ethics.”35 This was to be a source of tension for all subsequent medical practitioners and their societies.
During the Renaissance as the medical works of Greco-Roman authorities were rediscovered and translated into the vernacular, new scientific discoveries in anatomy and physiology challenged traditional, formal knowledge. The conflict that this caused brought another dimension to the doctor’s role: research scientist. How could he reconcile this with his ethical duty to serve his patients, the poor and the state? Who would support such research? How did this fit with the teachings of the Catholic and Protestant churches? All of these questions became especially acute when outbreaks of plague, Black Death and syphilis spread throughout western Europe from 1347 to 1700.
Did doctors have a duty to remain during disease outbreaks, or should they follow the Hippocratic injunction to “leave fast, go far and return slowly”? Although Martin Luther and many Catholic theologians argued that practitioners had a duty to stay, Calvinists and rabbinical writers said that educated people should flee to preserve their lives for the good of their society. The Great Plague in London clearly illustrated the conflict between self-preservation and social obligation when, as diarist Samuel Pepys recorded, the noted physician Dr. Goddard justified his flight in 1666 by claiming that he was simply following his patients who left for the countryside.36 An alternate view was expressed by apothecary C, who wrote:
Everyman that undertakes to bee of a profession or take on himself an office must take all parts of it, the good and the evil, the pleasure and the pain, the profit and the inconveniences all together and not pick and chuse; for Ministers must preach, Captains must fight and Physicians attend upon the sick.37
This idealistic view of medical ethics would continue to confound practitioners, patients, emperors and kings as each nation tried to define the roles and responsibilities of caregivers, care recipients and the state. But the contrast between the behaviour of a well-educated, prominent doctor and the actions of apothecaries, barber-surgeons and dissenting clergy also indicated the class structure of Stuart Britain and the limits of traditional knowledge when faced with communicable disease. How could doctors claim to be in a profession if they were unable to provide care and cure their patients?
By the 17th century, medicine in Great Britain had started to differentiate itself from the European model because the College of Physicians, established by Henry VIII in 1518 and given its Royal status by Charles II in 1660, promoted formal education at Oxford and Cambridge only for those who adhered to the Church of England. This created a small group of elite physicians who ministered to the Royal Court and the aristocracy but left other Britons and the armed forces seeking practitioners with less social eminence. Since many potential medical students came from dissenting families, they attended private schools like that of anatomist and surgeon John Hunter in London, worked and studied as apprentices with country practitioners, or increasingly went to the University of Edinburgh, which by the mid-18th century had surpassed the University of Leiden in the Netherlands with the quality of its teaching and its open admissions policy.38 Students from British North American colonies also attended the University of Edinburgh for both basic training and postgraduate work. This situation and the settlement of former military surgeons in the towns and cities of the United States and Canada during the late 18th and early 19th centuries ensured that British, rather than continental, ideas of medical ethics would predominate as the two new nations developed their own medical professions and codes of ethics.
Why were codes of ethics necessary? In Britain, medical practice had fragmented among physicians, surgeons and apothecaries, and the lack of central examining bodies or effective training meant that little quality control existed and that charlatans, quacks and itinerant healers flourished “because the market regulated practice [and] success depended upon a capacity to satisfy the public — by being inexpensive, [by] flattery, or by cutting a dash.”39 To counter such socially constructed choices and make medicine into a true profession not merely a trade, John Gregory (1725–1773), an Aberdeen-born physician trained at Edinburgh and Leiden who served as regent and professor of medicine at Aberdeen from 1746 to 1764 and then as professor of physic at the University of Edinburgh from 1764 to1773, wrote and published Lectures Upon the Duties and Qualifications of a Physician in 1772. This study distilled his views on the role and responsibilities of physicians and synthesized many of the philosophical concepts articulated by leaders of the Scottish Enlightenment such as David Hume, Adam Smith and Thomas Reid. All of these men were moral philosophers and expressed deep concern about the self-interest that dominated contemporary life.40 For Gregory, this was particularly evident in medical practice, where he saw the market forces of greed and self-interest replacing the moral qualities and intellectual understanding that characterized good medicine in his opinion. The self-interest displayed in treating the wealthy often resulted in excessive care for high fees, while the treatment of the worthy poor in local infirmaries was often a means to make one’s reputation and obtain wealthy patients. Neither form of medical care met Gregory’s standards because the care was not founded on either Baconian science or common sense ethical precepts, the most important of which he called “sympathy.” He defined this term as follows:
Portrait of John Gregory 1725 – 1773
Courtesy of Wellcome Library, London.
I come now to mention the moral qualities peculiarly required in the character of a physician. The chief of these is humanity; that sensibility of heart which makes us feel for the distresses of our fellow-creatures, and which, of consequence, incites us in the most powerful manner to relieve them. Sympathy produces an anxious attention to the thousand little circumstances that may tend to relieve the patient; an attention which money can never purchase: hence the inexpressible comfort of having a friend for a physician. Sympathy naturally engages the affection and confidence of a patient, which, in many cases, is of the utmost consequence to his recovery…. Men of the most compassionate tempers, by being daily conversant with scenes of distress, acquire in process of time that composure and firmness of mind so necessary in the practice of physick. They can feel whatever is amiable in pity, without suffering it to enervate or unman them.41
Gregory offered his students two ways to determine whether practitioners were displaying genuine sympathy: first, in spite of the challenges at hand, the doctor never called attention to his success; and second, he treated patients of all social classes with the same degree of compassion and care. In the deeply class-conscious society of his day, the latter was a revolutionary concept. Laurence McCullough argues that Gregory provided two of the three components that ensured medical professionalization by arguing in favour of evidence-based medicine and asserting that “physicians should make their primary commitment the protection and promotion of the health-related interests of patients and keep systematically secondary their own interests.”42 Gregory also criticized the guild mentality of many of his colleagues, and this was expanded on by his successor Thomas Percival (1740–1804), ] an English-born practitioner trained at Edinburgh and
Portrait of Thomas Percival (1740-1804)
From: Sketches of the lives...of the medical staff of Manchester Infirmary the University Press by: E.M. Brockbank Published: the University Press Manchester 1904. Courtesy of Wellcome Library, London.
Leiden who produced Medical Ethics, or a Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons in 1803.
Percival’s code in fact had been written nearly a decade earlier in response to problems that arose at the Manchester Infirmary when conflict among the medical staff caused it to close during an epidemic. Percival recognized that depending on practitioners to behave as “gentlemen” would not prevent the feuds and bad behaviour that jeopardized patient care and the profession’s public image. But more importantly, he argued that physicians had a fiduciary duty to put their patient’s interests ahead of their own and must earn public trust through service in hospitals, through appropriate conduct in private practice, in their “relations with apothecaries,” and in their services for judicial and public health authorities. This expanded role was the justification for professional self-regulation and meant that future disputes would be settled not through duels in the press or on the village green but through collegial compromise based on shared knowledge and competence.43
Cover page and Preface of Thomas Percival’s Medical Ethics, or, a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons.
Although his treatise would provide North Americans with the foundation for the first national codes of ethics, his proposal was not adopted by the British Medical Association when it was formed in 1857. The class structure and the continuing gap between university- and apprenticeship-trained physicians and surgeons meant that British definitions of professional behaviour were left to individual morality rather than being formalized in a code of ethics with legal consequences. But the General Medical Council that oversaw the quality of medical education from 1858 onward was given the responsibility of regulating its members’ conduct and had the power to “erase” doctors who transgressed from the Medical Register. Without a license from the Council, practitioners were not eligible to sue for fees or to participate in the national health insurance plan. Clearly, British doctors, medical educators, the public and the government believed that ethical conduct was “essentially a matter of personal character” that the profession itself could monitor and maintain.44 But would this approach work to protect the public and enhance the medical profession’s status in North America?
As the new American nation expanded after 1789, medical practitioners in the eastern cities began to emulate the New Jersey Medical Society, founded in 1766, by creating local societies to discuss the latest European discoveries and create professional unity. Many of these groups swore oaths derived from “the Hippocratic-style oaths then fashionable in Europe,” and in 1808, “the Boston Medical Society and its allied branches throughout the Commonwealth of Massachusetts attempted, with the sanction of the state legislature, to develop rules for self-regulation …” derived from Percival’s Medical Ethics (1803).45 As Robert Baker and his colleagues argue, this is the point at which the American and British approaches to medical ethics diverged because by incorporating “formal standards to justify specific acts of censorship and recommendations for expulsion,” the Americans were opting for professional self-regulation based on conduct, not character. Indeed, he and his co-authors emphasize the revolutionary nature of this development by stating: “The move from an ethics of character to one of conduct was thus an extension, in the social sphere of medicine, of the American ideological commitment to egalitarian democracy; for it meant that all persons were treated as moral equals.”46
While the elite of the American medical profession was engaged in refining professional conduct, American society was adopting Jacksonian democracy that eliminated state licensing requirements and encouraged individuals to serve as their own doctors or to use the services of Thomsonian botanics, homeopaths, eclectics and other untrained individuals. Between 1800 and 1840, the quality of medical education declined as the traditional four-year apprenticeship followed by stringent examination from a state medical board or the censors of a local medical society was replaced by training in medical colleges, some of which were associated with major universities while others were proprietary. Graduates of these institutions automatically were licensed, but their qualifications varied so widely that, in 1844, Dr. Nathan Smith Davis (1817–1904) presented a series of motions to the New York State Medical Society calling for a national conference to discuss how to improve American medical education. After further discussion in 1845, the conference opened in New York City on May 5, 1846, when 122 leading practitioners and medical educators quickly deadlocked over the issue of medical education. Dr. Isaac Hays (1796–1879) of Philadelphia, editor of the American Journal of Medical Sciences, saved the day by proposing another conference to create a national medical association whose purpose would be “for the protection of their [doctors’] interests, for the maintenance of their honour and respectability, for the advancement of their knowledge, and the extension of their usefulness” as well as to deal with pre-medical and medical training and to create a national code of medical ethics.47
Dr. Isaac Hays (1796-1879)
Portrait of Dr. Isaac Hays, American ophthalmologist, editor, American Journal of Medical Sciences. Image courtesy of Leon Morgenstern MD, Center for Health Care Ethics, Cedars-Sinai Medical Center, Los Angeles, Calif.
When the delegates met in Philadelphia in 1847, they not only supported the creation of the American Medical Association (AMA) but also approved the code of ethics prepared by Dr. John Bell’s (1796–1872) seven-man committee that included Isaac Hays as its editor and secretary. Drawing on Percival’s work, the 1847 code used the principle of reciprocity to justify “consensual professional authority” over the behaviour and practice of members. Bell told the attendees the following:
Every duty or obligation implies, both in equity and for its successful discharge, a corresponding right. As it is the duty of the physician to advise, so has he a right to be attentively and respectfully listened to. Being required to expose his health and life for the benefit of the community, he has a just claim, in return, on all its members, collectively and individually, for aid to carry out his measures, and for all possible tenderness and regard to prevent needlessly harassing calls on his services and unnecessary exhaustion of his benevolent sympathies.48
This concept infused the AMA “Code of Ethics,” which was divided into three chapters: Chapter 1 — Of the Duties of Physicians to Their Patients, and of the Obligations of Patients to Their Physicians; Chapter 2 — Of the Duties of Physicians to Each Other and to the Profession at Large; and Chapter 3 — Of the Duties of the Profession to the Public, and of the Obligations of the Public to the Profession. Each of these chapters was subdivided into articles that outlined the roles and responsibilities of doctors, patients and society and provided the agenda for reforming medical education and medical practice in America. Only once science had again become the foundation of medical education and quacks and other charlatans removed from membership in local and state medical societies could American medicine demonstrate that it conformed to the high moral precepts embodied in its code of ethics.
The impact of the 1847 code was immediate. Lay and medical periodicals reprinted it, claiming that it was equivalent to a second Declaration of Independence, and in 1855 medical reformers used this to justify requiring “all allied municipal, state, and county medical societies, as well as allied asylums, clinics, dispensaries, infirmaries, hospitals, and medical schools, and … all of their members” to subscribe to it. Beyond the United States, the code was reprinted in Berlin, London, Paris, Vienna and elsewhere.49 But was it a rallying point to reform the profession and medical practice or a self-interested attempt to eliminate competitors and codify the financial transaction at the centre of the doctor-patient relationship?
By the 1880s, some state and local societies began to question whether the AMA code represented ethics or etiquette. The New York State Medical Society was expelled from the AMA because its members wanted to be free to consult with homeopaths — an action explicitly forbidden in Chapter 2, Article IV, which states: “But no one can be considered a regular practitioner, or a fit associate in consultation, whose practice is based on an exclusive dogma, to the rejection of the accumulated experience of the profession, and of the aids actually furnished by anatomy, physiology, pathology and organic chemistry.”50 Further problems arose over issues such as advertising one’s services, promoting patent medicines or surgical instruments, adjusting fees based on length of service or the patient’s means, and whether to admit black or female practitioners to local societies. As a result of the conflict over consultation, many specialists left the AMA to create their own societies that did not have a code of ethics.51
In 1903 the AMA bowed to critics and replaced the code with the “Principles of Medical Ethics.” Since it also eliminated the Ethical and Judicial Council that had rendered decisions on ethical questions for the national body while making the principles voluntary, not mandatory, this situation “represented a significant retreat from the Percivallean ideal of professional self-regulation.” But by 1908 the AMA was once again considering re-establishing the code and the Judicial Council, and in 1911 the latter was recreated and then in 1912 the principles were revised “to address and resolve disputes and to respond to social change” by encouraging the specialists to rejoin and condemning practices such as fee splitting, commissions and contract practice.52 These changes coincided with Abraham Flexner’s report on medical education in North America, which condemned proprietary medical schools, argued in favour of the German model of scientific laboratory-based medical education and led to the standardization of medical training. Medical ethics were thus incorporated in professional practice from the beginning of a student’s education, and the student was expected to continue to conform to the principles promulgated by the AMA for the rest of his career.
In a burst of enthusiasm engendered by the creation of the new Canadian Confederation, 166 members of the medical elite gathered in Quebec City in October 1867 to discuss creating a national medical association. Prominent practitioners, medical educators and aspiring younger men agreed that a national body to promote the profession’s interests, define preclinical and clinical education, and create group cohesion was necessary. Like their American counterparts in the 1840s, Canadian doctors in the 1850s and 1860s faced significant competition from homeopaths, eclectics, patent medicine vendors and quacks. The public supported the sects or purchased remedies from patent medicine companies and local general stores because licensed doctors were available mainly in urban areas and many of the remedies that they prescribed were expensive, hard to take and sometimes deadly since calomel, a mercury derivative, and bloodletting were still in use. The gentle therapeutics and holistic approach of the homeopaths made them attractive to middle and upper class families. Only the poor who received free treatment from regularly trained men serving in local general hospitals or dispensaries, both of which were funded by charitable donations and small grants from municipal or provincial governments, were used to train students. One consequence of this was conflict among the various medical schools over clinical material — a battle that usually resulted from interpersonal rivalries. Clearly the Percivallean code had not penetrated the Toronto medical scene, where rival instructors and their students were charged with causing the deaths of hospital patients during the 1850s.53 To overcome this type of unprofessional behaviour, local medical societies began to form, in part to decide on fees and in part to discuss the latest European and American scientific advances.
By 1867 medical leaders agreed that the profession needed to put its house in order and during the initial meeting set up a committee on ethics to prepare a code. Dr. Charles Tupper, the former Premier of Nova Scotia and current member of Prime Minister John A. Macdonald’s Cabinet, served as president of the new group and, in his 1868 presidential address, observed that “I do not believe that any elaborate code of medical ethics is required.… The professional man who stands by that golden rule will exhibit in all his dealings, both with his professional brethren and the community at large, the character of the true gentleman, and will require little else, I believe, for his guidance.”54 While Tupper was illustrating the continuing British influence, his American-trained colleagues were modifying the AMA “Code of Ethics” to suit Canadian needs, with the result that Canadian doctors were expected to exemplify Christian moral character while incorporating the American understanding of fiduciary duties and responsibilities.55 [Brownell’s version of the 1868 CMA Code of Ethics]
One of the first results of the adoption of the “Canadian Medical Association (CMA) Code of Ethics” was an effort to eliminate doctors who consulted with sectarians from local medical societies unless they promised to desist from this behaviour. As the 19th century progressed, issues such as advertising cures for cancer, profiting from patent medicines, providing abortions and other forms of unbecoming conduct resulted in some doctors being disciplined by the provincial bodies charged with licensing and registration.56 This was a marked contrast to the American system even though medical professionals provided each tribunal’s membership.
But was the “CMA Code of Ethics” simply a disciplinary document? In 1881 Dr. William Canniff discussed the meaning of the code in his presidential address to the CMA. A former Dean of the Victoria College Medical School, Canniff was a well-regarded surgeon, public health activist and noted amateur historian.
Portrait of William Canniff (1830-1910)
Dr. William Canniff practiced surgery in Toronto and Belleville, taught pathology and surgery at Victoria College Medical School, and produced the first Canadian textbook in pathology (1866). He was a founding member of the Canadian Medical Association in 1867 and the Ontario Medical Association in 1880. He served as the president of the CMA (1880). Canniff authored the History of the Settlement of Upper Canada (1869) and The Medical Profession in Upper Canada (1894). Image courtesy of the Canadian Medical Association.
In his analysis of the code, Canniff used examples from his own practice to outline how the reciprocal duties of doctors and patients intertwined. He strongly believed that the practitioner’s major duty was to bring hope and comfort to the sick and that truth-telling must occur, especially for the dying. He reminded his audience of the importance of consultations for the sake of the patient but also that they must not consult the irregulars because they did not have the scientific training necessary for a proper diagnosis. He informed his listeners that many patients shopped around for medical assistance because they did not want to pay medical bills or because some doctors were more fashionable than others. And in a world where the doctor travelled to the patient, he noted the challenges associated with house calls, dinner time or evening demands for assistance and the unremitting nature of medical practice. To deal with these issues, he argued in favour of Christian forbearance, recommended that families purchase practitioners’ services through an annual retainer to ensure preventive rather than just curative treatment and urged annual holidays during which colleagues cared for each other’s patients.57 Shot through with Victorian moralism and paternalism, this speech nevertheless illustrates one of the few examples of the intersection of medical ethics and medical etiquette as interpreted by a Canadian doctor.
As medical specialties emerged and medical practice began to shift from home to office and hospital, Canadian doctors also faced questions regarding the future of the CMA. Who did it represent? Was it an effective instrument for influencing public opinion and shaping federal health policy? Growing conflict between general practitioners and specialists made developing the consensus necessary to persuade Parliament to pass the Medical Registration Act difficult. Even more frustrating, it took from 1902 to 1912 to get all the provinces to ratify the legislation that permitted a single portal of medical licensing, designed to overcome limiting practice to a single province and to ensure that Canadians who went to Great Britain had their qualifications recognized. Although Canadian doctors and Canadian medical schools contributed greatly to the war effort, by 1921 the CMA was foundering and needed to develop closer links with provincial associations and the profession at large in order to continue.58 One much needed change was updating the Code of Ethics. Rewritten in 20th century prose, the 1922 version eliminated the sections pertaining to patient’s obligations to their doctors, the public’s obligation to the profession and the sections regarding doctors’ duties to assist their fellow practitioners. In addition to simplifying interprofessional relations, the 1922 code condemned commissions and fee splitting, trends that had developed in tandem with specialization.59 It also stated that the doctor must “comport himself as a gentleman” [sic], become a member of his local, provincial and national medical associations and understand that the “Code of Ethics … is based upon the Golden Rule, that the principles enunciated are primarily for the good of the patient and the public at large, and that their observance and enforcement should be such as shall deserve and receive the hearty endorsement of the community.”60
Through the 1920s, the CMA sponsored three conferences on medical services that illustrated the changes occurring in medical education, medical practice, public relations and the emergence of interest in health insurance. The Great Depression of the 1930s brought payment for professional services to the fore as hard-pressed cities and hospitals continued to expect practitioners to provide free service. Although this had long been an accepted component of medical practice, the loss of paying patients meant that doctors no longer could afford to carry out extensive charitable work. One consequence was the first doctor’s strike in Canada, which occurred when Winnipeg’s medical community refused to continue providing free care to municipal relief recipients in the city’s hospitals in 1933.61 Was this action, the 1934 report of the CMA Committee on Economics supporting health insurance, and growing public interest in government-funded health care the impetus for the 1938 revisions to the Code of Ethics? Or had the creation of the Royal College of Physicians and Surgeons of Canada in 1929 and its adoption of the “CMA Code of Ethics” in 1930/31 been the spur for change? The Royal College was established to standardize the examination for specialty degrees, and its examiners required proof of candidates’ morals and ethics before they were allowed to take the exams. In fact, David Stewart, the chair of the CMA Ethics Committee, informed his colleagues that the original code had been written for the “age of gigs and saddle-bags” and needed to be updated to accommodate modern medical practice, including the role of doctors within hospitals, the necessity of maintaining one’s competence, the role of radio in advertising products and disseminating health knowledge, and group practice. He also argued that doctors misunderstood the code as a form of “statute law” and discipline when it “aims at ideals, not laws; to form good conduct, not to punish what is bad.”62
Dr. David Alexander Stewart (1874-1937)Dr Stewart graduated in medicine from Manitoba and after post-graduate training began a career in tuberculosis serving for 37 years until his death as Superintendent of the sanatorium at Ninette, Manitoba. He served as Chairman of the Committee on Ethics of the Canadian Medical Association--for whom he wrote a completely new Code of Ethics, published after his death. He felt the code “aims at ideals, not laws; to form good conduct, not to punish what is bad” (see text) Image courtesy of the Canadian Lung Association, www.lung.ca
In addition to revising the code to include new clauses dealing with abortion, locum tenens, relations with nurses and communicating with the laity, Stewart and his committee also included the Hippocratic Oath and the Prayer of Maimonides as well as quotations from noted medical authorities such as Francis Bacon, Louis Pasteur and Sir Thomas Browne in an effort to bridge the growing gap between the humanities and the biological sciences. And recognizing the impending possibility of a national health insurance program, the 1938 Code of Ethics stated the following:
Any general medical service for a nation should aim to prevent no less than to cure disease, guard individual choice of doctor, provide consultant and specialist service, demand from the profession regulation of the quality of professional services, interpose as little as possible between doctor and patient, advise with the organized profession and, if possible, arrange for nursing and hospital care.63
With this as its moral and ethical guide, the CMA Committee of Seven participated in the first, but ultimately unsuccessful, effort to create a national health insurance system during World War II.64
But public and professional belief in the altruistic and humanitarian motivation of the medical profession was shattered in 1945 by the revelations of human experimentation and mass killing by German doctors and scientists when the concentration camps were liberated and also when the Japanese mistreatment of prisoners and captured populations was exposed. After testimony from doctors and researchers about the ethics of medical research at the war crimes trials at Nuremberg, the presiding judges created the Nuremberg Code to define international standards for ethical use of human subjects. Concerned doctors, including T.C. Routley of the CMA, established the World Medical Association, whose “Declaration of Geneva” included clauses that stated: “I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient,” and “I will maintain the utmost respect for human life, from the time of conception; even under threat, I will not use my medical knowledge contrary to the laws of humanity.” When the “CMA Code of Ethics” was revised in 1956, the “Declaration of Geneva” was added to the end of the document, demonstrating the impact of both the war and the international efforts to create shared professional understanding of patients’ rights and doctors’ ethical imperatives. The 1956 revision also included an opting out provision for practitioners whose religious beliefs forbade inducing abortions when the mother’s life was threatened, changes to rules of conduct for consultations and the recognition that prepaid hospital and medical services plans required doctors to secure their patients’ consent to sharing information. And with regard to nurses and nursing, the code recognized the important service that nurses provided, stating that “it is the duty of all doctors to support and, where necessary, guide the work of nurses to the end that both professions, while remaining true to their respective codes of ethics, will so cooperate as a harmonious team that there will be provided an optimal service to all patients under their care.”65
The 1960s were a tumultuous decade for Canadians and their doctors. The national hospital and diagnostic services plan had been introduced in 1958, and by 1962 all of the provinces and territories were receiving federal funds to ensure citizens had access to these necessary services. Although the Royal Commission on Health Services had been appointed in 1961, the Saskatchewan government proceeded to develop and implement a provincial medical services insurance program that, in spite of strong opposition from the medical profession and its supporters, went into operation on July 1, 1962. Many of the province’s doctors refused to open their offices or left for annual vacations to protest what they saw as “civil conscription.” The work stoppage lasted 23 days and resulted in the death of a baby with meningitis on July 1. Had the doctors ignored their ethical duties? Or were they justified in their opposition to potential government interference in the doctor-patient relationship? Certainly the rhetoric that they used to justify their opposition reflected the phrasing of the World Medical Association “International Code of Medical Ethics,” which stated that it was unethical to be “taking part in any plan of medical care in which the doctor does not have professional independence.”66 But who was to interpret the term “professional independence”? The profession? The government? After the Saskatoon settlement, the province’s doctors discovered that the Medical Care Insurance Commission was primarily an accounting group and that little changed except that patients were now able to access medical services without fear of financial loss. Indeed by the mid-1960s, Saskatchewan’s doctors were among the highest paid because they no longer had to write off bad debts or provide charity services. Not surprisingly, the Royal Commission on Health Services recommended that the rest of the country adopt this made-in-Canada solution to the rising cost of medical services, provided that the terms were acceptable to those giving and those receiving the services in its 1964 report.
The World Medical Association international code had appeared in the 1961 revision of the CMA code, which now also allowed doctors to bill insurance companies and other prepaid plans for services that they rendered to their colleagues’ families. Further changes in 1963 and 1965 stressed the international code’s prohibition on sharing confidential information without signed patient consent in the former and a new clause regarding patient and practitioner safeguards for sterilization in the latter.67 But as the Saskatchewan conflict had demonstrated, the medical profession was undergoing significant change as the CMA and the country approached their centennials. Were the traditional values that had been the focus of all previous codes still relevant?
From 1947 to the present, medical practice and research have changed dramatically. The discovery of DNA in 1953 opened new fields of research in genetics, while surgical advances including transplantation led to much more active intervention for cardiac and end-stage renal disease patients. The development of the oral contraceptive made providing birth control information an important component of general practice. Improvements in diagnostic technology such as ultrasounds, CAT and PET scans permit earlier discovery of tumours and birth defects, while dialysis machines enable individuals with renal disease to live longer. New drugs to treat various forms of cancer have improved survival rates, while statins and selective serotonin reuptake inhibitors enable individuals with high cholesterol and depression to manage their conditions. All of these advances have contributed to the emergence of a modified form of medical ethics — bioethics — because all of them and the growing concern about dying with dignity raised legitimate questions about the roles and responsibilities of doctors, patients, other health care professionals, families and the public.
Bioethics evolved during the 1970s as western societies grappled with the challenges that emerged in the 1960s. Civil rights, second wave feminism, the anti-establishment counter-culture, opposition to nuclear war and environmental concerns all contributed to eroding deference to many forms of authority, including organized medicine.68 The Canadian Medical Association (CMA) recognized the need to change the code of ethics to meet these new conditions and, from 1968 to 1970, revised it by dividing it into two sections: the first was “terse statements of direction to members on the basic principles of medical ethics by which it governed itself,” while the second explained how practitioners were to conduct their relationships with “patients, colleagues and society.”69 In this version the CMA explicitly stated that its role was to define ethical behaviour for all Canadian doctors, although the Royal College of Physicians and Surgeons of Canada also had an active ethics committee. In recognition of the social and political changes that were occurring, the 1970 code noted “a patient’s right to reject any recommended medical care,” the doctor’s duty to provide continuity of care, the need to resolve personal morality with advice on options for care, and the concept of death with dignity and support after clinical death as a prelude to organ donation for transplantation.70 All of these changes indicated the extent to which the benign paternalism of all previous codes was being altered in response to changing public attitudes and expectations.
The Royal College of Physicians and Surgeons of Canada also engaged in the public debate as a result of its longstanding commitment to ethical conduct by its fellows. In 1946 the Royal College had listed moral and ethical standing as the first requirement for candidates who sought its certification. In 1952 it established a committee on ethics that, like the CMA committee, encouraged Canadian medical schools to teach the subject to their students. In 1973 the College appointed a committee to examine the future of specialty training and accreditation from a broad perspective. The committee reported that professionalism was eroding and argued that the College had a duty to use its publications and meetings to accomplish two objectives: first, to “reinforce … the ethical basis of medical practice” by “examining the major ethical issues facing specialty healthcare,” and, second, “to offer leadership to the non-medical public … on what is in the best interests of exemplary and compassionate patient care rather than what is best for the profession, in the event that the two do not coincide.”71 In 1977 after a speech on “Bioethics and the Leadership of the Medical Profession” by Dr. Jacques Genest, the College created the Bioethics Committee, which worked with the CMA, the College of Family Physicians of Canada and the National Council of Ethics in Human Research to examine issues such as “informed consent, euthanasia, human organ sales, allocation of resources and physicians’ relations with the pharmaceutical industry.…”72 All of these topics were to be part of each resident’s training as she/he was socialized in the ethical requirements of medical research and practice. And the discussion papers were published in the Annals of the Royal College of Physicians and Surgeons of Canada to ensure that current specialists were aware of contemporary issues and the requisite ethical standards that must be met.
For Canadians, the bioethical debates were deeply meaningful if they were seeking assistance with reproductive issues, facing crucial decisions regarding life-sustaining care for elderly parents or premature infants, or dealing with choices regarding treatment for cancer, stroke or end-stage renal disease. But in the late 1970s and early 1980s, the majority of the population was far more concerned about access to doctors and hospitals, extra billing for medical services and opting out by specialists. These resource and payment issues made headlines and led to the passage of the Canada Health Act, which united previous federal health program legislation to reinforce the four guiding principles and add a fifth — accessibility — to ensure that the Canadian medicare system continued to serve citizens. Once again angry medical practitioners challenged politicians’ right to determine whether they would charge their patients more than the amount that the provincial health insurance plan paid for specific services. In June 1986 the Ontario Medical Association staged a 25-day strike that ultimately prompted the Ontario College of Physicians and Surgeons to remind the province’s doctors of their legal and ethical obligations to provide patient care. As Eric Meslin noted: “Universal health care is based upon a principle of justice that focuses not on physicians but on society. It is therefore deemed fair to the extent that no one who is qualified to receive medical or health care benefits will be denied those benefits. On the other hand, the system is not deemed fair (or unfair) to the extent that physicians are more or less able to secure economic and professional autonomy.”73 This was the heart of the conflict because the Code of Ethics stressed the doctor’s fiduciary duty to an individual patient and said little about how she/he was to reconcile that responsibility with participation in government-funded health plans.
To respond to the continuing concern about health system funding and the increasing number of bioethical challenges that arose when the HIV/AIDS epidemic erupted, the CMA created a department of ethics and legal affairs that assisted the Ethics Committee in revising the code in 1990, lobbying against Bill C-43 on abortion and presenting a brief to the Royal Commission on Reproductive Technologies.74 The 1990 revision used gender-neutral language in recognition of the increasing number of women in the profession, and the committee indicated that a major revision was needed to address contemporary concerns such as “euthanasia; confidentiality of medical records; advance directives and resuscitation of the terminally ill; proxy decision-making; and the relationship between physicians and the pharmaceutical industry.”75 In 1996 the results appeared in a new code that opened with a historical preface citing the Hippocratic Oath and recent bioethical discussion as the foundation of the “fundamental ethical principles of medicine, especially compassion, beneficence, nonmaleficence, respect for persons and justice.”76 For the first time, the code applied to students and residents as well as licensed practitioners. And the authors made it clear that the code was a general document setting standards rather than providing detailed policy directives. The content of the various sections demonstrated clearly that the decorum that had dominated previous versions had been replaced by a strong focus on patient’s rights, the importance of effective communication, especially for end-of-life decisions or incompetent patients, full disclosure to research subjects regarding the nature of the clinical trial and their right to withdraw at any time without forfeiting continuing care, recognition of the determinants of health and the physician’s “responsibilities to promote fair access to healthcare resources,” support for human rights, participation in the peer review process, and taking the initiative to seek personal help if suffering from problems that would “adversely affect physician’s services to patients, society, or the profession.”77
Through the 1980s and 1990s as governments cut funding for health care and later limited places in medical schools, both the CMA and the Royal College continued to press Canadian medical schools to increase the time devoted to analyzing the ethical issues that their graduates would face in practice. The CMA advocated for “ethics rounds” in hospitals, while the Royal College conducted surveys of medical school curricula and supported the preparation of bioethics study modules. In contrast to the past when moral character and appropriate ethical behaviour based on Judeo-Christian religious beliefs were criteria for admission to medical training and specialist certification, sustained discussion of the ethical attributes of Canadian practitioners has developed because of the complexity of health care challenges and because teamwork requires an understanding and appreciation of the ethical views of all the participants in Canada’s increasingly multicultural society. In 2004 the CMA issued an update of the Code of Ethics that added accountability to its list of fundamental principles and shifted the focus from individual patients to society’s needs while still maintaining the doctor’s advocacy role on behalf of patients and the resources to care for them. Physicians were urged to guard their professional integrity, to contribute to professional development “through clinical practice, research, teaching, administration or advocating on behalf of the profession or the public,” to “take all reasonable steps to prevent harm to patients; should harm occur, disclose it to the patient,” and to “recognize that self-regulation of the profession is a privilege and that each physician has a continuing responsibility to merit this privilege and to support its institutions.”78 https://policybase.cma.ca/documents/policypdf/PD19-03.pdf These priorities indicate how greatly medical practice has changed since the original code was devised in 1868 and suggest that it is vital for Canadian doctors to understand the context in which the Code of Ethics was created and to recognize their role in fostering and implementing future changes that respond to changes in medical practice and social needs.
What does it mean to be a doctor? How greatly should tradition affect contemporary beliefs and practices? As this primer has demonstrated, the evolution of medical ethics has mirrored the spiritual beliefs and practices of many different societies. From polytheistic civilizations to monotheistic nations, health and disease have compelled each society and its specially trained caregivers to grapple with the moral and ethical issues that underpin every diagnosis and treatment decision. For western-trained practitioners, the Hippocratic corpus and Judeo-Christian religious principles were united to create a tradition of medical ethics that emphasized the doctor’s duty to do no harm and to serve the sick without expectation of payment. However, in an emerging capitalist economy, such self-abnegation seemed appropriate for religious orders but not to medieval guilds.
How could Hippocratic and Christian ethics be reconciled with making a living by caring for the sick? For many centuries, the apprenticeship system of medical training provided a means to socialize future physicians in the clinical and ethical dimensions of their craft. But since many patients were unable to pay for trained medical assistance, doctors were faced with competition from various sects such as homeopaths, eclectics and botanics, as well as charlatans and quacks. And, as indicated earlier, many of their practices and remedies were dangerous and debilitating, which limited public confidence in their knowledge and expertise. By the 18th century, John Gregory and Thomas Percival were vigorously questioning the medical deontology and decorum of Hippocratic ethics, and their treatises provided the impetus for a new, collective approach to medical ethics and practice. Both the American and Canadian medical associations assumed the role of ethics watchdog, in part to create a shared national professional culture and in part to justify their claims to guide health policy-making at all levels in both federal systems.
But is there an “internal” morality to medicine that is not part of wider social values? Should the “nature of the clinical encounter between physician and patient” supersede the traditional understanding that the basis of medical ethics resides in moral character as displayed in carrying out the duties that constitute a moral life? Are compassion, beneficence, non-maleficence, respect for persons, justice and accountability not also characteristic of the ethical codes of other groups such as nurses, teachers and civil servants, for example? While American experts such as Edmund Pellegrino79 and Robert Veatch80 debate the matter, have the majority of Canadian medical practitioners, residents and students discussed it among themselves and with their patients, their families and the public? In today’s pluralistic society, does the Hippocratic Oath still have relevance for medical students? Are residents provided with the opportunity to review bioethical questions with their teammates, their patients and their patients’ families in an atmosphere that does not automatically privilege medical knowledge? What role do non-medical bioethicists perform? Is their task to remind doctors that considerations beyond specific treatments affect the quality of life and the ease of dying? Medicine has always been the intersection between science and society, practised as both an art and a craft. The written ethical codes that guide behaviour are supplemented by the socialization that occurs during medical training and throughout physicians’ careers. Clearly, the definition of what constitutes ethical standards changes as social mores are modified and new scientific discoveries extend or limit our capacity to prevent, cure or palliate disease.
As this historical survey has demonstrated, medical oaths and codes of ethics blend the moral precepts, normative behaviour and social duties of the civilization in which they are used. In Mesopotamia, ancient Egypt, Hellenic Greece, India, China, the early Ottoman Empire and pre-Renaissance Europe, each society defined its expectations of physician behaviour based on existing religious/spiritual and medical knowledge and practice. But it was the Greeks who most clearly articulated the ethical principles on which the western medical tradition was founded: beneficence, confidentiality and admonitions against actions that would harm the patient. The Hippocratic Oath, however, said nothing about payment for services rendered because Greek society revered personal honour more than wealth. This produced the “paradoxical duality of the conflict between altruism and self-interest” that ethicists see at the heart of western codes of ethics.
Formal ethical codes developed as medicine shifted from theory to scientific experimentation and individual apprenticeship training gave way to medical courses. These codes also mirrored the larger forces that were reshaping the economic and social structure as feudalism and its class system was replaced by capitalism and western forms of democracy. As John Gregory and Thomas Percival demonstrated, the traditional understanding of professional training and behaviour required modification to eliminate self-interest and justify the profession’s claim to direct its own destiny and collect fees. The concept of fiduciary duty and shared responsibilities permeates the original codes of ethics of the American Medical Association and the Canadian Medical Association because both groups were staking their claims to expertise to be used to serve society in a complex and contested marketplace. As medical training improved and research provided preventive measures, antibiotics and vaccines, new surgical techniques and diagnostic technology, medicine acquired the status and prestige that it had long sought by the middle of the 20th century.
The very success of medical science, however, led western European nations and Canada to move medical practice from the commercial realm to public policy through the creation of government-funded hospital, medical and diagnostic services in the 1950s and 1960s. Only the United States has failed to create a universal health program for its citizens, which means that the benefits of the many therapeutic advances and new pharmaceutical discoveries are restricted to those who can purchase them. By making medical services a right of citizenship and a public good, Canadian and European governments were creating a social contract with their citizens and the medical profession. But as the conflicts in 1962 and 1986 as well as smaller work stoppages in various provinces indicate, many doctors continued to believe that their ethical code required them to defend the sanctity of the doctor-patient relationship against third party intrusion. The public and various commentators, however, viewed these strikes as self-interest, and respect for the medical profession declined. Indeed, one of the most striking features of the late 20th century was the resurgence of non-traditional health practices. From the 1960s to the present, Canadians have turned to midwives, naturopaths, homeopaths, chiropractors, osteopaths, traditional Chinese medicine, acupuncture, holistic healing and Aboriginal spiritual practices in response to growing concern about the quality of care and the disjunction between lay and professional understanding of disease states and therapies.
As this development was occurring, the medical profession itself was undergoing significant change. Women and representatives of the various ethnic groups who migrated to Canada from the 1960s on were slowly gaining places in Canadian medical schools, where they started to challenge the unwritten codes of conduct that governed the profession. Why should doctors be expected to work endless shifts as interns and residents? What provisions for maternity leave should be provided during training? Why were specialties rather than family medicine valorized during training? Were western medical techniques appropriate in treating non-western patients, or should their requests for complementary services be honoured? When these internal issues were added to the external challenges posed by bioethics, the medical profession began to review the training process and the code of ethics, with the result that the 1990 and 1996 revisions recognized the importance of communicating clearly with patients, ensuring that bioethical questions were resolved and that doctors understood their personal responsibility to maintain their own health as well as that of their patients.
To respond to funding cuts and growing public concern about the sustainability of the Canadian medicare system, the Canadian Medical Association issued its updated “CMA Charter for Physicians” in 1999. This document stated that “Canadian physicians regard serving the health needs of their patients as paramount, and put this at the centre of the patient-physician relationship. A strong patient-physician relationship is one based on trust, honesty, confidentiality and mutual respect.”81 The charter also stressed the importance of professional integrity based on compliance with the “CMA Code of Ethics,” fairness at the individual and collective levels of training and practice, and the importance of work-life balance, and argued for a “vital role” in determining the future of the health care system. This assertion of professional values was paralleled by the work of an international committee that produced “Medical Professionalism in the New Millennium: A Physician Charter” in 2002. [http://www.acponline.org/running_practice/ethics/physicians_charter/] This charter identified three fundamental principles — the primacy of patient welfare, patient autonomy and social justice — as the foundation of 21st century medical professionalism. It also outlined a set of 10 professional responsibilities and concluded that “professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health.”82 These views and values were incorporated in the 2004 “CMA Code of Ethics,” [https://policybase.cma.ca/documents/policypdf/PD04-06.pdf] but, as this primer has demonstrated, although new roles bring new responsibilities, the fundamental commitment to compassion and beneficence must remain at the core of medical ethics.
Baker, Robert, Dorothy Parker and Roy Porter, eds. The Codification of Medical Morality: Historical and Philosophical Studies of the Formalization of Western Medical Morality in the Eighteenth and Nineteenth Centuries. Vol. 1. Medical Ethics and Etiquette in the Eighteenth Century. Dordrecht: Kluwer Academic Publishers, 1993.
Baker, Robert, editor. The Codification of Medical Morality: Historical and Philosophical Studies of the Formalization of Western Medical Morality in the Eighteenth and Nineteenth Centuries. Vol. 2. Anglo-American Medical Ethics and Medical Jurisprudence in the Nineteenth Century. Dordrecht: Kluwer Academic Publishers, 1993.
Baker, Robert B. Arthur L. Caplan, Linda L. Emanuel and Stephen R. Latham, editors, The American Medical Ethics Revolution: How the AMA’s Code of Ethics Transformed Physician’s Relationships to Patients, Professionals, and Society. Baltimore and London: Johns Hopkins University Press, 1999.
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics, 6th ed. New York: Oxford University Press, 2008.
Brownell, A. Keith W., and Elizabeth “Libby” Brownell, “The Canadian Medical Association Code of Ethics 1868 to 1996: A Primer for Medical Educators,” Annals of the Royal College of Physicians and Surgeons of Canada, 35, 4 (June 2002): 241.
Bynum, W.F., Anne Hardy, Stephen Jacyna, Christopher Lawerence, E.M. Tansey, Lawrence I. Conrad, Michael Neve, Vivian Nutton, Roy Porter and Andrew Wear, editors. The Western Medical Tradition, 2 Vols. Vol. 1: 800 BC to AD 1800. Vol 2: 1800-2000. Cambridge and New York: Cambridge University Press, 2009.
Cruess, Richard L., Sylvia R. Cruess and Yvonne Steinert. Teaching Medical Professionalism. New York: Cambridge University Press, 2009.
Jones, James W., Laurence B. McCullough, Bruce W. Richman. The Ethics of Surgical Practice: Cases, Dilemmas, and Resolutions. New York, Toronto: Oxford University Press, 2008.
Jonsen, Albert. The Birth of Bioethics. New York: Oxford University Press, 1998.
Jonsen, Albert. A Short History of Medical Ethics. New York: Oxford University Press, 2000.
McCullough, Laurence. John Gregory and the Invention of Professional Medical Ethics and the Profession of Medicine. Dordrecht: Kluwer Academic Publishers, 1998.
“Medical Professionalism in the New Millennium: A Physician Charter,” Annals of Internal Medicine 136, no. 3 (February 5, 2002) : 243–246. Available at http://www.annals.org/cgi/content/full/136/3/243.
Percival, Thomas. Medical Ethics; or, a Code of Institutes and Precepts: Adapted to the Professional Conduct of Physicians and Surgeons, together with an introduction by Edmund D. Pellegrino. Birmingham, Ala: Classics of Medicine Library, c1985, 1803.
Porter, Roy. The Greatest Benefit to Mankind: A Medical History of Humanity From Antiquity to the Present. London: HarperCollins Publishers, 1999.
The President’s Council on Bioethics. Available at: http://www.bioethics.gov/ President’s Council Reports are available at: https://bioethicsarchive.georgetown.edu/pcsbi/studies.html accessed October 9, 2009.
The Royal College of Physicians and Surgeons of Canada. “Cases and Primers of the Royal College Bioethics Education Project.” October 9, 2009.
Rothman, David J. Strangers at the Bedside: A History of how Law and Bioethics Transformed Medical Decision Making. New York: Basic Books, 1991.
Sherwin, Susan. No Longer Patient: Feminist Ethics and Health Care. Philadelphia: Temple University Press, 1992.
Singer, Peter A., editor Bioethics at the Bedside: A Clinician’s Guide. Ottawa: Canadian Medical Association, 1999.
Singer, Peter A., editor in chief, A. M. Viens, executive editor. The Cambridge Textbook of Bioethics. Cambridge; New York; Cambridge University Press, 2008.
Steinbock, Bonnie, editor. The Oxford Handbook of Bioethics. New York; Toronto: Oxford University Press, 2007.
Temkin, Owsei. Hippocrates in a World of Pagans and Christians. Baltimore: John Hopkins University Press, 1991.
Veatch, Robert M. Dialogue Disrupted: Medical Ethics and the Collapse of Physician-Humanist Communication, (1770–1980). Oxford: Oxford University Press, 2005.
- World Medical Association, International Code of Medical Ethics (Pilanesberg, South Africa: World Medical Association, 2006). Available at https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/international-code-of-medical-ethics-2006/#.
- Medical Professionalism in the New Millennium: A Physician Charter,Annals of Internal Medicine (February 5, 2002) 136, 3: 243-246. Available at http://www.annals.org/cgi/content/full/136/3/243.
- Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity From Antiquity to the Present (London: HarperCollins Publishers, 1999), 44–45.
- Porter, 47–50.
- Porter, 62.
- Vivian Nutton, “Medicine in the Greek World, 800–50BC,” in Lawrence I. Conrad, Michael Neve, Vivian Nutton, Roy Porter and Andrew Wear, editors, The Western Medical Tradition: 800BC to AD 1800 (Cambridge and New York: Cambridge University Press, 1995), 11.
- Leon Kass, “The Hippocratic Oath,” in Being Human: Readings From the President’s Council on Bioethics (Washington: President’s Council on Bioethics, 2003), 122. Also available at http://bioethics.georgetown.edu/pcbe/bookshelf/reader/chapter3.html#reading.
- Albert Jonsen, A Short History of Medical Ethics (New York: Oxford University Press, 2000), 7. Jonsen says the term dóxa is more subtle than the word reputation and should be understood as “the reflection of the inner self to others, the external manifestation of moral virtue.”
- Heinrich von Staden, “In a pure and holy way”: Personal and Professional Conduct in the Hippocratic Oath? Journal of the History of Medicine and Allied Sciences 51 (1996): 404–417.
- von Staden, 417–437; Jonsen, 8.
- Jonsen, 8.
- Jonsen, 9.
- Porter, 62.
- Porter, 140.
- Jonsen, 40.
- Porter, 149–151.
- Porter, 158–159.
- Jonsen, 40.
- Porter, 159–162.
- Jonsen, 40.
- Jonsen, 40.
- Porter, 70.
- Porter, 74.
- Porter, 78–79.
- Porter, 82.
- Jonsen, 13–18.
- Jonsen, 19–20.
- Jonsen, 20.
- Jonsen, 20, 23.
- Jonsen, 22.
- Jonsen, 22.
- Jonsen, 24. The original source for this material is J.J. Walsh, The Popes and Science: The History of the Papal Relations to Science During the Middle Ages and Down to Our Own Time (New York: Fordham University Press, 1911), 419–423.
- Jonsen, 25.
- Jonsen, 25.
- Jonsen, 45–46.
- Cited in Jonsen, 46.
- Porter, 286–291.
- Porter, 289.
- Robert M. Veatch, Dialogue Disrupted: Medical Ethics and the Collapse of Physician-Humanist Communication (1770–1980) (Oxford: Oxford University Press, 2005), 8–15.
- Lawrence B. McCullough, “John Gregory’s Medical Ethics and the Reform of Medical Practice in Eighteenth-Century Edinburgh,” Journal of the Royal College of Physicians of Edinburgh, (2006):89–90, cited in Reference 13.
- McCullough, 91.
- Jonsen, 58-60. See also Chester R. Burns, “Moral Philosophy and Medical Ethics Before 1846,” in Robert B. Baker, Arthur L. Caplan, Linda L. Emanuel and Stephen R. Latham, editors, The American Medical Ethics Revolution: How the AMA’s Code of Ethics Transformed Physician’s Relationships to Patients, Professionals, and Society (Baltimore and London: Johns Hopkins University Press, 1999), 6–7.
- �Introduction,� in Baker et al., The American Medical Ethics Revolution, xix–xx.
- Ibid., xxi–xxii.
- Ibid., xxiii.
- Ibid., xxiv–xxvi.
- Ibid., xxvii. The full text of Bell’s introduction to the motion is found in Appendix B of The American Medical Ethics Revolution, 317–323.
- Ibid., xxviii. See Appendix C, 324–334 for a copy of the code.
- Jonsen, 71.
- �Introduction,� in Baker et al., The American Medical Ethics Revolution, xxx.
- Ibid., xxx–xxxi.
- Charles M. Godfrey, Medicine for Ontario: A History (Belleville: Mika Publishing Company, 1979), 75–81.
- �The President's Address,� Canada Medical Journal, 4 (October 1868): 173�174.
- C. David Naylor, “The CMA’s First Code of Ethics: Medical Morality or Borrowed Ideology?” Journal of Canadian Studies 17, no. 4 (1982-1983): 20–33. See CMA Code of Ethics 1868
- Ronald Hamowy, Canadian Medicine: A Study in Restricted Entry (Vancouver: The Fraser Institute, 1984), 95–130, 168–172.
- William Canniff, “Presidential Address,” Canada Lancet, 14, 1 (Sept 1881): 387–392.
- H.E. MacDermot, History of the Canadian Medical Association, Volume II (Toronto: Murray Printing and Gravure Limited, 1958).
- A. Keith W. Brownell and Elizabeth “Libby” Brownell, “The Canadian Medical Association Code of Ethics 1868 to 1996: A Primer for Medical Educators,” Annals of the Royal College of Physicians and Surgeons of Canada, 35, 4 (June 2002): 241.
- Canadian Medical Association Code of Ethics 1922, transcribed from the original by A. Keith W. Brownell and Elizabeth “Libby” Brownell, April 2001. The Brownells have transcribed all of the revisions to the Code of Ethics from 1868 to 1996. The 1928 and 1929 revisions were even more vehement in their denunciation of commissions and fee splitting, which indicates that the gap between payments to general practitioners and payments to specialists remained a source of conflict. See Brownell's Introductory Remarks and Photos
- C. David Naylor, “Canada’s First Doctor’s Strike: Medical Relief in Winnipeg, 1932–4,” Canadian Historical Review 67, 2 (1986): 151–180.
- David A. Stewart, “The Ethics of Medical Practice,” Canadian Medical Association Journal (March 1936): 325–326.
- Canadian Medical Association Code of Ethics 1938, transcribed from the original by Brownell and Brownell, April 2001. See CMA Code of Ethics 1938
- C. David Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911–1966 (Montreal and Kingston: McGill-Queen’s University Press, 1986).
- Canadian Medical Association Code of Ethics 1956, transcribed from the original by Brownell and Brownell, April 2001. See CMA Code of Ethics 1956
- Canadian Medical Association Code of Ethics 1961, transcribed by Brownell and Brownell, April 2001.
- Canadian Medical Association Code of Ethics 1963, transcribed by Brownell and Brownell, April 2001, 5, and Canadian Medical Association Code of Ethics 1965, transcribed by Brownell and Brownell, April 2001. See Brownell's Introductory Remarks and Photos, CMA Code of Ethics 1961, CMA Code of Ethics 1963, CMA Code of Ethics 1965
- Douglas Owram, Born At The Right Time (Toronto: University of Toronto Press, 1997).
- John Sutton Bennett, History of the Canadian Medical Association, 1954–1994 (Ottawa: Canadian Medical Association, 1996), 209.
- Brownell and Brownell, 242. See also Canadian Medical Association Code of Ethics 1970, transcribed by Brownell and Brownell, April 2001. See CMA Code of Ethics 1970
- G. Ross Langley, A. Keith W. Brownell and John F. Seely, “Ethics, Professionalism and the Royal College” in The Evolution of Specialty Medicine 1979–2004 (Ottawa: The Royal College of Physicians and Surgeons, 2004), 310.
- Ibid., 312.
- Eric M. Meslin, “The Moral Costs of the Ontario Physicians’ Strike,” Hastings Center Report 17, 4 (Aug.-Sept. 1987): 13.
- John Sutton Bennett, History of the Canadian Medical Association, 1954–1994 (Ottawa: Canadian Medical Association, 1996), 213.
- Ibid., 214.
- �Code of Ethics of the Canadian Medical Association,� Canadian Medical Association Journal 155, 8 (October 15, 1996).
- Brownell and Brownell, 242. See CMA Code of Ethics 1996
- See http://www.cma.ca/index.php?ci_id=53556&la_id=1.
- Edmund D. Pellegrino, “One Hundred and Fifty Years Later: The Moral Status and Relevance of the AMA Code of Ethics,” in Baker et al., The American Medical Ethics Revolution, 107–123.
- Robert M. Veatch, “The Impossibility of a Morality Internal to Medicine,” Journal of Medicine and Philosophy 26, 6 (2001): 621–642.
- See http://www.cma.ca/index.php?ci_id=53576&la_id=1.
- See Lancet 359 (2002): 520–522; Annals of Internal Medicine (2002): 243–246.
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CMA Code of Ethics 1922
CMA Code of Ethics 1928
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