By: Lindsey Grubbs
And certainly, there are longstanding principles that have shown little alteration. Don’t harm your patients (though we might quibble over what constitutes harm). Don’t have sex with them. Don’t tell their secrets. Try to be good at your job. Much else, though, has changed, and these differences over time reveal the changing shape of the medical profession and its ethical concerns. Looking at the Code of Medical Ethics adopted at the founding of the American Medical Association (AMA) in 1847, for example, sheds light on the status of medicine in both the nineteenth and twenty-first centuries.
In the mid-nineteenth century, the medical profession was a much hazier thing than it is today, with no real system of professional legitimization: one did not have to attend medical school or pass exams to become a physician. The doctor on the corner might be university-educated, trained through apprenticeship, or a total quack. While a small medical elite held university professorships or wealthy, fashionable client lists, this status was typically conferred though familial or social connections.
A virulent professional war raged between “regular” (university-trained doctors using allopathic methods) and “irregular” (homeopathic and folk) physicians. Although today’s patients would likely tend toward the former, the violence and ineffectiveness of many early medical methods may have skewed preferences the other way: an herbal remedy would likely leave a patient feeling better than an anesthetic-less surgery or purgative-induced vomiting and diarrhea.
The AMA’s first code was about fifteen pages long, divided into three chapters: on the mutual obligations of physicians and patients; on duties to the profession and other doctors; and on the mutual obligations of physicians and the public.
Although the first of these chapters seems most foundational, it is, rather strikingly, the second that is the longest and most detailed, suggesting that internal professional matters trumped patient duties. Above all, the chapter calls for cohesion within the group and “emphatic testimony against quackery in all its forms.” To clarify the difference between their legitimate practice and money-hungry quackery, they mustn’t “resort to public advertisements” or take out patents on new medical devices, and must constantly adhere to standard medical treatments to avoid the stain of homeopathic cure-alls (98).
Rather heroically, the authors write: “Impressed with the nobleness of their vocation, as trustees of science and almoners of benevolence and charity, physicians should use unceasing vigilance to prevent the introduction into their body of those who have not been prepared by a suitable preparatory moral and intellectual training” (90). Those who have entered the profession legitimately, though, are bound to show a united front, with a “general harmony in doctrine and practice.” They must eschew competition, thus avoiding—rather dramatically—“heartburnings and jealousies.” An incredibly detailed account of the logistics of secondary consultations (i.e., the consulting physician must enter the room after the attending physician, must consult in private, and must adhere to protocols in case of disagreement so as not to diminish their profession’s status) shows the intense anxiety surrounding any possible loss of (already shaky) public faith in their abilities.
Another of the most telling features of the 1847 Code is that the chapter establishing the mutual duties of physicians and patients spends more space outlining patients’ duties to physicians than vice versa. Among these are the doctor’s right to be “actively and respectfully listened to” and be granted the same level of professional respect given to clergymen and lawyers, to which he is “eminently entitle[d].” Patients are meant to put ultimate trust in their physicians—not seeking second opinions or ignoring their advice—without pestering them. They should call on their doctors as early in the day as possible and not “weary” them with “a tedious detail of events.” In the end, the code asserts that patients must never forget their gratitude for those who heal them.
Reaffirming the group’s quest for professional status, the document asserts, “The first duty of a patient is, to select as his medical adviser one who has received a regular professional education.” It continues, “In no trade or occupation, do mankind rely on the skill of an untaught artist,” and medicine is “confessedly the most difficult and intricate of the sciences.” Moreover, the patient should not just attend to the training, but to the personality of the physician: they must give preference to those who disregard “company” and “pleasure” (95). Doctoring was both an intellectual and a moral endeavor.
Despite some persistent values, medical ethics are responsive to cultural changes and particularly to revealed abuses. (For example, the influential Nuremburg Code, a foundational document in human research ethics, emerged directly from the atrocities of Nazi Germany.) Today’s AMA code, then, looks radically different from the code of 1847. The most recent code, adopted in June 2016, is billed as authoritative and modern. Although beginning with a one-page document laying out general ethical principles, it now has 11 chapters, some longer than the entire 1847 code (including chapters on “genetics & reproductive medicine” and “organ procurement & transplantation” which may have sounded alarming and Frankenstein-ian to the 1847 crowd). In all, it is 560 pages long (and available to the general public for a mere $59.95, though it can be read for free here)—and this enormous tome is hardly a regular touchstone for practicing physicians, who are more likely to call in ethics consultations with specialists on difficult cases.
Reflecting on how overtly political the 1847 code now looks, we might ask what today’s code reflects about the medical profession’s largest professional organization—who is included and excluded from the august group? Despite it’s visibility, a relatively small number of physicians today are members of the AMA—although around 75% of American physicians were members in the 1950s, the number has fallen, by some accounts to as low as 15%. In one indication, less than ten years ago, the AMA apologized for their history of discrimination against black physicians and patients. No organization can represent the ethical views of an entire profession, especially one so often in contact with complicated moral situations surrounding, for instance, reproductive health, abortion services, or end-of-life care.
Indeed, the group was caught in controversy during the early days of Donald Trump’s presidency as the Chair of the AMA’s board endorsed Tom Price, a prominent opponent to the Affordable Care Act, on behalf of the association. Many physicians disagreed with the endorsement, publishing a disavowal of the statement, and a call for physicians to engage in policy to support vulnerable patient populations.
Speaking of patient vulnerability, considering strong evidence of differential healthcare and patient outcomes on the basis of social identities like race (see here and here and here) and gender (see this excellent op-ed), it is notable how rarely bias comes up in the code. Could we imagine a revised code of ethics speaking directly to these failures, institutionalizing anti-racism and anti-sexism as a cornerstone of ethical health care?
Or one that acknowledges that the ethical response may be in direct contradiction with law or government policy? For instance, in a devastating op-ed for the New York Times, M. Gregg Bloche outlines the role of C.I.A. physicians in perpetrating torture, calling on them to reject any (currently theoretical) orders from the Trump administration to assist with torture programs.
Ethics are not set in stone--they move and respond to shifts in culture. Debates that would have been unimaginable in the nineteenth century are now common. What will readers in 150 years (knock on wood) see that we cannot?
 Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 89.
 Justine Murison, “Quacks, Nostrums, and Miraculous Cures: Narratives of Medical Modernity in the Nineteenth-Century United States,” Literature and Medicine 32.2 (2014): 419-440.
 Starr, 91-2.
 If this seems surprising, it is worth noting that honesty as a primary virtue is a relative newcomer to the medical field. In an oft-cited study, Novack gathered questionnaire results in 1961 indicating that 90% of physicians preferred to withhold a cancer diagnosis, while a follow up in 1979 showed a sea change, with 97% of physicians preferring to share the information.