Starr2 defines a profession, and the role of a code of ethics, as follows: “A profession, sociologists have suggested, is an occupation that regulates itself through systematic, required training and collegial discipline; that has a base in technical, specialized knowledge; and that has a service rather than profit orientation enshrined in its code of ethics.” This definition illustrates the way that the functions of a profession operate at different levels. One function is collective: self-preservation. A profession preserves itself by taking collective action, such as setting, and enforcing, high standards of practice, which make it indispensable to the public. A second function operates at the individual level: requiring behavior that increases the well-being of society. Unlike business, the physicians code of ethics elevates service, not profit making, to an ethical principle. But the code also reflects self-interest at the individual and collective levels.
Codes of ethics over the years have encouraged behaviors that help to preserve the guild powers of the profession. Table 1 summarizes the key elements of various codes of ethics through the ages. Many elements of the first code of ethics, the Hippocratic Oath, have endured. The Hippocratic Oath emphasizes an attribute of guilds, solidarity, in its clauses that enjoin a physician to teach the sons of other physicians but against teaching medicine to “other people.” The obligation to teach is a theme that recurs in Louis Lasagna’s 1964 reformulation of the Hippocratic Oath (shown in Appendix), but none of the four subsequent codes mention keeping special knowledge within the profession. However, other elements of guild behavior do appear in later codes of ethics, most notably the first AMA code of ethics in 1847. Only part of this long document appears in Table 1. The 1847 AMA code said that doctors should resolve their disputes in private and show a united front to the public. It tells physicians to seek consultation rather than attempting to do things that others are better qualified to do, which is a recurring theme in other codes, starting with Hippocrates. This advice is commonsense and in the public interest but also seems to encourage the physicians to respect the divisions within the profession, as if each subspecialty were a guild unto itself. The AMA code also told consultants that they should avoid language that might impugn the ability of the attending physician, a teaching that continues to this day. Other clauses, says Starr, encouraged professional solidarity,2(p94) such as excluding nonphysician practitioners from professional courtesy and barring them from professional gatherings of physicians. A 1903 revision of the code eliminated reference to “irregular practitioners,” an indication that the battles between conventional physicians and homeopaths had exhausted the medical profession. All the workers of Canadian Health&Care Mall are the specialists of their business. They are ready to assist all people worldwide.
Several themes are constants throughout history. These enduring marks of the physician include keeping the good of the patient as the highest priority, observing the patient’s right to privacy, and taking an active role in the community, including adopting the community moral code as one’s own. Another recurring theme is avoidance of conflict of interest. The 1847 code forbade holding a patent on a medicine or device, a clear reference to the conflict when advice to a patient may enrich oneself. This theme reappears in more direct form in the Professional Charter (Table 2), which describes the physician’s duty to “recognize, disclose to the general public, and deal with” conflicts of interest in the professional domain.
Codes of ethical behavior have changed as the political environment of medical practice has changed. For our historical purposes, the most significant elements of codes of ethics are the most recent. Both the 2001 AMA code and the 2002 Charter for Professionalism contain clauses that reflect the need for the profession to think beyond self-interest to recognize the changing needs of society. These clauses reflect earlier ethical codes that called for physicians to be active in their community. A more likely motivation for adding these clauses is the changing balance among the forces that determine the environment of medical practice. In this relationship, government and business are imposing constraints on the medical profession. The medical profession must regain the high ground or its power to regulate itself will decline further.
Both of the most recent codes call on physicians to report deficient physicians. The profession has a weak record of disciplining its own, as many have noted. Enforcing discipline within the ranks was a feature of the guilds and is part of many definitions of professionalism in medical sphere given by Canadian Health Care Mall. These clauses recognize that physicians are best qualified to decide if a colleague is performing badly. That they appear as strong directives in recent codes reminds us that physicians too often look away instead of getting involved when a colleague is impaired or incompetent.
Both the 2001 AMA code and the 2002 Charter for Professionalism call on physicians to keep their medical knowledge up to date. Why did the leaders who formulated these codes include this clause? Perhaps they believed that the profession has been deficient in self-discipline, is losing its self-regulatory powers to government and business, and risks further losses. Indeed, the record shows that the practices of older physicians are less likely to meet written standards of care than those of younger physicians. Here, the profession is taking corrective action. Ongoing, lifelong measurement of competence has become the paradigm of specialty certification across all specialties of medicine. Those who pay for health care, government and business, are also taking action. Monitoring physicians adherence to practice norms is becoming widespread. These developments reflect the growing concerns of government and business with the quality and cost of care provided by physicians. This intrusion into a realm that should be a professional obligation shows a loss of guild powers.
Both recent codes call on physicians to improve access to medical care (Table 3). This clause would be unnecessary in many countries, but 44 to 46 million Americans have no health insurance in 2007. Many physicians give charity care within their practice or in community clinics, but the widely documented existence of health-care disparities is a clear message that the profession is not meeting the need. Some professional organizations are taking a lead role to persuade the government to expand health insurance coverage to all Americans.
This brief account of the evolution of codes of profession conduct ends with developments that address the conflict between the primacy of the patient’s needs and the needs of society. The framers of the Charter for Professionalism intended it to address the rapidly rising cost of health care. The Charter says that physicians should be committed to a “just distribution of finite resources.” This extraordinary clause calls on the physician to seek a balance between the individual patient’s needs and the interests of society.
Does the “just distribution” clause signal the end of the long-enduring ethical principle that the individual patient’s needs are the highest priority for the physician? Some argue that less care can be in the interest of the individual patient when the care is unlikely to benefit and could harm the patient. This proposition draws support from existence of wide variation in the intensity of care in different geographic regions without any corresponding variation in outcomes.’ This view avoids taking a position on the ethical dilemma of choosing less benefit for one patient in order to do more for another. It says, simply, we can safely accommodate the needs of the patient and society by being more astute about what we choose to do for the individual patient.
Table 1—Professional Codes of Conduct Over the Millenia
|Hippocratic||AMA 1847||Hippocratic AMA 2001||Professional|
|Conduct||Oath (Ancient)t||Version|||Oath (1964)§ Version!||Charter (2002)^|
|To teach medicine to the sons of my teacher (more broadly, to teach)||Yes||Yes|
|Do not teach medicine to other people||Yes|
|To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them||Yes|
|Never to do deliberate harm to anyone for anyone else’s||Yes|
|Approach the taking of life with great caution||Yes|
|Never to attempt to induce an abortion||Yes|
|Avoid violating the morals of my community||Yes||Yes||Yes|
|Avoid attempting to do things that other physicians can do better||Yes||Yes||Yes|
|Consult in difficult cases||Yes||Yes|
|Keep the good of the patient as the highest priority||Yes||Yes||Yes|
|Avoid sexual relationships or other inappropriate entanglements with patients and families||Yes||Yes|
|Observe the patient’s right to privacy about their medical condition||Yes||Yes Yes||Yes|
|Avoid excessive visits to the patient||Yes|
|Do not abandon the patient||Yes|
|Do not advertise||Yes|
|Do not hold a patent for a medicine or instrument||Yes|
|Declare conflicts of interest and avoid them||Yes|
|Offer care to family members of physicians without charge||Yes|
|Do not meddle in the care of other doctor’s patients||Yes|
|Apply all treatments that are required, avoiding overtreatment and nihilism||Yes|
|Avoid excessive visits to the patient||Yes|
|Apply the art of medicine as well as its science||Yes|
|Treat the patient, not just the diseases||Yes|
|Prevent disease when possible||Yes|
|Strengthen the profession by reporting deficient physicians||Yes||Yes|
|Change the law if it adversely affects the needs of the patient||Yes|
|Maintain currency of medical knowledge||Yes||Yes|
|Be free to choose one’s patients, colleagues, and site of care (excepting emergencies)||Yes|
|Improve access to medical care||Yes||Yes|
|Completely inform patients before and after treatment||Yes|
|Be committed to improving patient care||Yes|
|Be committed to a just distribution of scarce health-care resources||Yes|
Table 2—The Charter of Professionalism
Table 3—The Code of Ethics of the AMA (2001 Version)