By RICHARD GUNDERMAN, MD
Last 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.”