Thomas Percival. Discussing the foundation of Medical Ethics

Abstract

Background and aim of the work: In 1803, the English physician Thomas Percival published Medical Ethics, a work destined to become a milestone in the development of modern codes of medical ethics, starting from the first edition of the American Medical Association’s ethical code. Notwithstanding the undeniable influence that this book has exerted upon the codification of the principles of medical ethics, researchers and experts foster different and opposing points of views on its real nature. They question whether Medical Ethics truly belongs to the literary genre of codes of medical ethics or, better yet, to that of medical etiquettes. Methods:This debate is crucial in the field both of medical history and of medical ethics, with regard not only to Percival’s work, but also to the ethical value of the current codes of medical ethics and deontology. Results:The lack of a rigorous philosophical-moral analysis of the current medical codification is reflected in its mere loyalty to the legal regulation, in substantial continuity with the past. However, the constant challenges proposed by the biomedical development, require the need to rethink the traditional conceptual tools of the current codes of medical ethics, with the purpose to achieve new schemes and innovative solutions. Conclusions:On this perspective, when the codes of medical ethics are worked out by physicians, they could be considered as wrongly titled medical etiquettes. This consideration could regard current codes of medical ethics, that remain faithful to tradition and that would more probably be codes of medical etiquette with a wrong title. (www.actabiomedica.it)

Introduction

As the eighteenth century drew to an end, Europe experienced the effects of urbanisation as a consequence of the industrial revolution. A great part of the population moves into big cities for economic opportunities, but they also often face diseases, misery and indigence. Thanks to the doctrine of the Enlightenment that breathes new life into the principle of tolerance, an emerging sense of help and support toward lower classes starts to enliven the modernisation of hospitals, which are now seen as medical institutions devoted to the social dimension of public health.

This notwithstanding, soon hospital institutions turn out to be difficult to manage. The main causes of the problem seem to stem from the medical practice itself. The presence of compulsory regulations and statutes, characterised by strict policies on available resources undermines the prescriptive authority of physicians and surgeons. Furthermore, several inner contrasts overshadow the medical profession, which is divided into three main groups: physicians, surgeons and pharmacists. Periodically, these tensions result in hostilities and threaten the esprit de corps and unity of the medical profession and as a consequence its stability and development.

Within this difficult context, the English physician Thomas Percival conceived his Medical Ethics (1), that has successively inspired modern codes of medical ethics (the first example was the Code of ethics by the American Medical Association, dated 1847), which organically collect the rules of conduct for physicians. However, another mainstream of thought states that it is not possible to address to Percival the foundation of medical ethics’ codification in Western society (2, 3). If this second perspective would be the correct one, how could we qualify modern codes of medical ethics? Should these codes be discussed with regard to their belonging to the field of medical ethics? Or differently to Percival’s code, modern codes should be treated as part of medical ethics on the basis of their upgrade?

In any case, Percival’s work is crucial both in the field of study of history of medicine and in that of medical ethics, in that it reconstructs the history of the codification of medical ethics’ evolution. From this perspective, the recognition of its importance is widely shared, even if its knowledge within the field of history of medicine, medicine and moral philosophy is, especially in Europe, not so widespread as it would deserve.

1. Medical Ethics or Medical Jurisprudence?

Together with the problems that are oppressing medical facilities, in 1789 Manchester is swept away by an epidemic of typhus, which seriously endangers the operational efficiency of its hospital.

In order to solve the organisational problems, the managers of the hospital double the number of the staff members. Unfortunately, the increasing number of the personnel causes several internal quarrels, which in 1791, as the epidemic is still flaring up, lead even to the closure of the ward dedicated to the care fever. The subsequent scandal forces the managers to designate one of the hospital’s most authoritative members, Thomas Percival, to work out a code of conduct with the aim of disciplining the behaviours of the staff (4).

Many similar works precede Thomas Percival’s Medical Ethics. Amongst others: Lectures on the Duties and Qualifications of a Physician by John Gregory, “On the Duties of a Physician” in Enquiry into the Duties of Men in the Higher and Middle Classes of Society in Great Britain by Thomas Gisborne and Statuta Moralia by the Royal College of Physicians in London. Notwithstanding this, Percival states that such works do not contain the specific references to the competences and tasks of medical professionals. A gap that he wants to fill in by detecting the rules of conduct directly within the field of medical practice, thus taking into consideration several medical statutes and regulations already existing.

With the aim to create a work, which would have stuck to the real needs of physicians in their professional practice, Percival has long discussions on its main contents with friends and colleagues. On this purpose, in 1792 the first chapter of the book is published and in 1794 the entire work is edited for private distribution. It is worth noting that the first draft of the work is titled Medical Jurisprudence, as it is originally conceived as a neat collection of those regulations which are already ruling the medical conduct of the professionals who work at Manchester hospital. The title Medical Ethics appears only in 1803 with the final edition dedicated to his son who has decided to undertake the medical profession. The choice of the title seems to be suggested by some friends, who may have persuaded Percival to substitute the term “jurisprudence” with that of “ethics”, as the latter mainly enshrines the duty to respect both legal and ethical rules.

Anyway, the first title cannot go unnoticed, as it introduces the controversy on the work’s real nature. Can the contents of Percival’s work be actually considered as the foundation of medical ethics and the related reflection on the principles of medical morality? Or better yet, is the book just a collection of rules of conduct, which comes into being and dies within the mere practice of the physicians who worked in an English hospital where the main problem was that of mutual respect and the living up to the medical profession’s good name?

As a matter of fact, the formal office to which Percival was entrusted coincides with his declared purpose: writing down a sort of guide for health professionals (physicians, surgeons, pharmacists) who work in his hospital, which is first of all useful to define their roles and related responsibilities, together with the rules of good fellowship. It is worth noting the wide interest of this work in the legal aspects of medical practice. In fact, the book devotes a whole chapter (the fourth) to the regulation of the physician’s behaviour in the cases «which require a knowledge of law».

Considering the task entrusted to Percival, his own purpose and the book’ broad interest in the legal aspects, the first title (“Medical Jurisprudence”) could apparently seem the most appropriate in order to define the work. However, even if this book was specific part of the regulations issued for Manchester hospital, it cannot be included in the body of Manchester (or England) health and medical laws. As a consequence, Percival’s friends were right to propose him to change the previous title “Medical Jurisprudence”. But was the decision by Percival to substitute this title with that of “Medical Ethics” actually the correct one?

2. Medical Ethics or Medical Etiquette?

In the course of the eighteenth century, even though several physicians still inspire their professional conduct to individual conscience and good sense by following a personal “code of honour”, some efforts to systematise physicians’ duties and bans into specific lists start to appear. These first approaches to the codification of what is fair and unfair in medical practice can be considered as evident examples of medical etiquette. The literary genre of medical etiquette stems from the reflection of a single physician, often famous and authoritative, who proposes himself as an ideal model for his readers. Hence, being it the result of a formulation, which is not shared by all colleagues, its guidelines do not provide sanctions in case of inobservance.

Medical etiquettes seem to be inappropriate to face the new challenges brought about by the medical profession, such as the struggle against several quack physicians and the social control of public health through the claims of exclusive competences, the defence of dignity and unity of professional (5), the warrant of a trusty relationship with untutored patients who are then unable to evaluate the services they receive (6). In this light, to fulfil the task of working out shared documents, which are able to identify the profession also from outside, the newly born medical associations or Orders formulate for their subscribers some codes of conduct, which are occasionally endowed with disciplinary enforceability. In mid-Southern Europe, these documents are called “codes of medical deontology”, whilst in the Anglo-Saxon culture they are known as “codes of medical ethics” (7).

The matter which is here called into question is the attribution of modern medical ethics to Percival and his work Medical Ethics.

First of all, the term itself “medical ethics” (or “professional ethics” or “practical ethics”) can not be addressed to Percival. In fact, this expression existed in the English literature long before Percival’s work was published (8). Some examples could be the works by Charles Davenant (9), David Fordyce (10), the abovementioned Thomas Gisborne, who used the definition of “applied moral philosophy” and David Hume who analyses the notion of “practical morals” to distinguish it from more abstract speculations.

Beyond the question referring to the invention of the definition “medical ethics”, it is worth noting the controversy, which derives from the interpretations of the real nature of Percival’s work. The crucial point is whether it should be enlisted among the works on medical ethics (defining Percival as a moral philosopher) and consider it as the first European code of medical ethics (11), or appreciate it as a mere collection of rules on medical etiquette.

As regards the substance, the basic difference between medical ethics and medical etiquette lays in the fact that the former concentrates on a wide-ranging reflection, which covers various fields from the intra-professional conduct to the doctor-patient and society relationship. The latter merely regulates the behaviour among physicians, on the basis of the principle of mutual courtesy.

According to some researchers, Percival’s Medical Ethics would be composed of sensitive and profound reflections, which make it not only a timeless work amongst the greatest classics (12), but better yet a milestone in Western medical ethics (13, 14). Behind the misleading concept of professional decorum, in its innermost essence the work enshrines a solid and definable moral theory, the ethical theory of virtue, chosen and applied by Percival to medicine after years of studies on moral philosophy (15, 16). Hence, Medical Ethics would have brought about a definitive separation between the old Ippocratic ethics and modern ethics (17, 18). becoming the first modern Code of medical ethics (19, 20), whose precepts would have remained unchanged up to the present (21).

After all, according to other authors, it seems more convincing the stance of those who state that Percival’s work merely represents a set of maxims and aphorisms of intra-professional etiquette, which aims only at regulating good fellowship (22). In the work, there is no evidence of moral-philosophical analyses, which aim at exploring the general aspects of ethics, since the main purposes of the book are only those of perpetuating the paternalistic spirit of medicine and propagandizing the monopolistic tendency and cooperative system of the medical profession (13). Because of its being “withdrawn”, this book seems to side with a corporatist sense with the main purpose to safeguard the medical team’s interests. In fact, we should not forget that Percival, as a conservative man, wrote his work in a time in which the English medical corporations, that had an elitist structure, were undergoing a democratic strike, especially by the liberal economic conception. To face it, he opposed a model of profession as a whole of unity and integrity in front of society.

To sum up, unless we do not opt for a special meaning of “ethics”, such as that of «morally permissible standards of conduct governing members of a group simply because they are members of that group» (23), Percival’s book cannot be evaluated as a work of medical ethics. But, if we agree that Medical Ethics is a wrongly titled work of medical etiquette, how should we assess modern codes of medical ethics, which have their background in Percival’s book? In fact, if that of Percival is not a work of medical ethics, how could current codes on medical ethics be considered as such?

3. Medical Ethics or Paternalistic Medical Ethics?

Come abbiamo detto, Medical Ethics’ wide spreading, that exceeded the expectations of its Author, is undeniable (24). In the decades following the publication of Medical Ethics, both in England and in Scotland several hospitals and medical associations, amongst which the Manchester Medico-Ethical Association and the British Medical Association, take inspiration from its language and contents to self-regulate the medical profession. The fame of Medical Ethics spread overseas, in particular in the United States, where several professional bodies based their own ethical codes on Percival’s work, even sometimes copying word by word some procedures contained in the book, as in the case of the Boston Medical Society. Moreover, in 1847, a group of American physicians, amongst others Benjamin Rush and Isaac Hays, took Percival’s Code as the backbone for the development of the ethical code of the newly born American Medical Association, which had been crafted one year before by Nathan Smith Davis with the purpose of promoting high levels of quality in medical education and professional practice.

As a result of such influence that Percival had on modern codes of medical ethics, we should legitimately expect a certain continuity between Percival’s book and modern codes. But if, as we have already pointed out, Percival’s Code is a work of medical etiquette, how is it possible that modern codes are documents of medical ethics?

One could say that current codes, even if they are based upon the (togliere) Percival’s work, show evident differences to it. In particular, they would reflect the moral maturation of contemporary society, by marking the conversion from the Hippocratic approach, steeped in medical paternalism and corporatism, to contemporary medical ethics that recognizes the patient’s central value in the care relationship.

Indeed, Percival’s work just represents the umpteenth effort to reassess the Ippocratic medical ethics (25), as it lacks in significant originality if compared to its original source (17). Indeed, Percival’s perspective is evidently conservative with regard to the traditional ethical paradigm, which he however tries to adapt to the hospital practice of his times (26), with the principal aim to maintain the classical division into physicians, surgeons, and pharmacists to stress the duty of mutual respect of their own competences and related hierarchical roles.

However, is it also true that modern codes have outdated the Hippocratic and paternalistic tradition, showing a full sensitivity towards medical behaviour which aims at safeguarding not only professionals, but also patients?

In order to answer this question, we look at what happens when the principles of medical ethics are recognised by and translated into Codes of conduct, which one should not forget, are worked out by medical associations composed almost exclusively by physicians. So far, the noble moral reflection on the ethical implications of medical practice is often replaced by a list of behaviours according to which the hierarchy relating to the good of the patient (and society) and the good of physicians (and their category) is not always clear. Besides, as we have seen, the main historical reason which leads to the formulation of codes of medical ethics is not the defence of a person’s interests, but rather the will to create a kind of “internal contract”, however recognised at a social level, aimed at claiming and defending the medico-centric perspective of the healthcare organisation, together with the monopolistic interest and paternalistic model of the profession. Then again there is a conflict of interests, obviously: if this is really about reaching a new foundation of medical ethics on a social basis, the authors of the professional regulations should not be exclusively physicians. They should pretty include representations of patients, or at least provide a consultation with associations of health care services’ consumers.

In addition to the presence of a practical “openness” to the external dimension (that should not be only stated by general principles, but also achieved within the rules of conduct), one thinks to what other fundamental features are needed to identify a code of conduct as a document of medical ethics. These features emphasise, on the one hand, the presence of a conscious and organic moral-philosophical reflection on the ethical theory choosen the code, and, on the other hand, the use of a method of rational justification for the selection of the rules of conduct.

In the long run, also these features will not be part of modern codes of medical ethics. In order to fill this gap, experts in moral philosophy (at present a small part of the commissions responsible for the elaboration of codes, should be included among the codes’ authors.

To conclude, we argue that if the critical overview set on Percival’s work is correct, the same logic should be applied to current codes of medical ethics.

Conclusion

Percival’s Medical Ethics is not a work on moral philosophy applied to medicine, but rather a book inspired on the one hand to the method of positive law and, on the other hand to the principles, which could be also religious, of traditional ethics. Its twofold purpose is to establish harmony among the conflicting factions at the hospital of Manchester and defend the corporatist interests of the medical profession. To this extent, amongst the various literary genres to which the codes of conduct for physicians could be attributed, the one that better fits Percival’s work is the medical etiquette. Anyway, Medical Ethics has undoubtedly left an indelible mark in the history of medical ethics, as well as in the history of medicine, and it should be considered as a fundamental reference for those who study this subject. Again, this aspect reinforces the difference between medical ethics and its related codification by a medical hand.

Reflections on medical ethics have no boundaries. The subject is stimulated from within by several moral theories and paradigms, which are developed on the basis of issues evaluated by rational justifications. Medical ethics is moral philosophy when it examines every sensitive issue that is directly or indirectly raised by medicine from its focal nucleus: the patient not only as an object but also as a subject of medical care (27). In the age of Percival, it is worth mentioning John Gregory (28), whose reflection, based on the moral philosophy of David Hume, stems from the idea that the doctor-patient relationship should be the core interest of medical ethics, and that society should be free to decide for its own good-health, even though that means to discourage the privileges of the medical class. Alternatively, we could hold up as an example Rev. Thomas Gisborne (29), whose work, less fortunate than those of Percival and Gregory, aims at giving priority to patients, rather than to physicians.

The codification of medical ethics consists in the declension of the principles of medical ethics by self-regulating the medical conduct in which, to every professional duty corresponds a right. In this light, it is more likely that the codes of medical ethics remain faithful to tradition, instead of accepting new moral interpretations, according to which a patient increasingly gains a central role (30). In other terms, if the codes of medical ethics are worked out by the bodies, which represent the profession rather than society, these would more probably be codes of medical etiquette with wrong titles. This is exactly the case of Thomas Percival’s Medical Ethics.