modernizing Code of Medical Ethics

flying cadeuciiLast month the American Medical Association wrapped up its annual meeting in Chicago, where it has reached the final stages of modernizing its 167-year-old Code of Medical Ethics, last updated more than 50 years ago.  The central role of ethics in medicine is reflected in the fact that, at the AMA’s first meeting in 1847, it treated the establishment of a code of ethics as one of its two principal orders of business.  Much in medicine has changed since 1847, but this founding document, which most physicians and patients have never seen, still offers important insights that deserve to be reaffirmed.

Spanning 15 pages, the 1847 Code of Ethics addressed just three fundamental concerns: the duties physicians and patients owe each other, physicians’ duties to each other and the profession at large, and the reciprocal duties of the profession and the public.  This structure, focused on moral duties, evinces an important feature of the authors’ view of medicine.  Namely, medicine is essentially a moral enterprise, grounded in mutual responsibilities, in which patients, physicians, and the public unite to serve the interests of the suffering.

In fact, the preamble to the 1847 Code of Ethics states explicitly that medical ethics “must rest on the basis of religion and morality.”  Ethics is not merely a matter of consensus, and the boundaries of professional ethics are not outlined by what a particular patient or physician might happen to agree to.  The fact that an employment contract or informed consent form has been signed is insufficient.  Professional ethics requires loyalty to ideals that transcend any particular person or group of people.  Like taking an oath, it rests on the presumption that professionals serve something higher than themselves.

The preamble to the 1847 Code also acknowledges that, in framing their code of ethics, the authors have “the inestimable advantage of deducing its rules from the conduct of many eminent physicians who have adorned the profession by their learning and piety.”  It explicitly holds up the example of the “Father of Medicine,” Hippocrates, by whose conduct and writing the duties of a physician “have never been more beautifully exemplified.”  The Code’s authors emphasize that these ideals are not only aspirational but achievable, having been exemplified by “many.”

The first chapter stresses the physician’s duty to answer the call of the sick, which is all the more deep and enduring “because there is no tribunal other than the physician’s own conscience to adjudge penalties for neglect.”  In other words, the Code entrusts the ethics of medical practice not to lawmakers, the courts, or hospital executives, but to the conscience of each physician.  We can detect and punish violators, the Code’s authors are saying, but it is impossible to legislate goodness, whose flame must ultimately burn nowhere else but in the hearts of professionals themselves.

The first chapter also states explicitly that physicians should never abandon a patient because a case is deemed incurable.  In an era obsessed with improving measurable outcomes such as length of stay and cost of care, many of today’s healthcare leaders need a reminder that a physician’s contribution cannot be fully assayed in terms of cures.  Incurable does not mean hopeless, and it is always possible to care well even for those who are dying.  The authors state that physicians should strive to be “ministers of hope and comfort to the sick.”

In our day of shifting insurance contracts and medical super-specialization, physicians and patients are often strangers to one another.  The second chapter of the Code stresses that, as much as possible, patients should entrust their family’s care to one physician, enabling a relationship to build over time.  Simply knowing a patient’s vital signs, physical examination findings, and laboratory test results is not enough.  The Code’s authors recognize that good medicine requires physicians to know their patients’ life circumstances, including the families and communities of which they are a part.

In stressing that physicians should be devoted to ends beyond self, the Code also invokes gratitude on the part of patients.  The services physicians render, it says, “are of such a character that no mere pecuniary acknowledgment can repay them.”  What transpires between patients and physicians, in other words, is not primarily an economic exchange.  Simply tending to the elements of a legal contract would not completely fulfill it.  To the contrary, the intimacy and dedication at the core of a good patient-physician relationship should inspire enduring gratitude.

Today we tend to see medicine as a scientific enterprise, placing our hopes in the advancement of knowledge and technology.  But in the second chapter, the Code of Ethics argues that “no scientific attainments can compensate for want of moral principles.”  Everyone holds out the hope of cures for cancer and Alzheimer’s disease, but good medicine is not merely good science.  Science helps us understand how to relieve suffering, but it does not explain why should want to relieve suffering in the first place.  For that, we must look to ethics and such extra-scientific virtues as compassion.

Today we take for granted the mass marketing of healthcare.  But the 1847 Code regards advertising as “derogatory to the dignity of the profession.”  There is an important difference between advertising and educating, and the two are not always easy to distinguish from one another.  One aims primarily at inducing a customer to spend money, while the other seeks mainly to serve the needs of a patient.  To advertise is to make a plea for customer’s business, thereby placing the relationship on a primarily economic footing, while educating treats the dignity of the patient as primary.

This helps to explain why the Code tends to avoid terms such as payment, preferring instead the seemingly awkward formulation of “pecuniary acknowledgment.”  In our day, healthcare reform has come to be understood to be about paying for healthcare, focusing primarily on questions such as who pays and how much.  To the authors of the AMA’s first Code of Ethics, however, medicine is not a commodity that can be delivered from the back of a truck like a refrigerator.  At its best, it much more closely resembles a friendship, a relationship that can never be bought and sold.

The third chapter of the Code declares that there is no profession that more freely dispenses charitable services than medicine.  A profession is defined in part by the fact that its members aspire to something beyond money, suggesting that physicians should naturally put tending to patients ahead of the money that the provision of services might or might not generate.  In fact, the opportunity to care for a patient pro bono, for good, constitutes one of the most self-defining and reinforcing activities in which professionals can engage.

In our own day, federal and state programs have led many physicians to expect to be compensated for all the care they provide.  But the Code calls upon physicians always to care for individuals in indigent circumstances “cheerfully and freely.”  It regards the care of the indigent not as an unfortunate burden that physicians must grin and bear, but as a positive opportunity.  It is not enough merely to provide such care.  It must also be done from the professional’s own free will and even cheerfully, because it is in doing so that professionals give life to what they really believe in.

Some might suppose that a medical code of ethics dating back 167 years could not possibly speak to contemporary physicians and patients.  After all, such a code predates the discovery of x-rays, antibiotics, and the structure of DNA.  Yet even as medical science evolves at an ever-quickening pace, the core of professional ethics remains essentially unchanged, in large part because goodness is grounded in human character.  It is impossible to be a good doctor without first being a good person.  As the AMA seeks to “modernize” its Code of Ethics, it would do well to return to the enduring insights of its founders.

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