Medical Ethics at the Millennium: a Brief Retrospective

• Publication year: 1997
• Pages: 141
• Citation: Vol. 26 No. 6 Pg. 141

26 Colo.Law. 141 Colorado Lawyer 1997.

1997, June, Pg. 141. Medical Ethics at the Millennium: A Brief Retrospective

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Vol. 26, No. 6, Pg. 141

The Colorado Lawyer
June 1997
Vol. 26, No. 6 [Page 141]

Specialty Law Columns
Health Law Forum
Medical Ethics at the Millennium: A Brief Retrospective
by Susan Fox Buchanan

Column Ed.: Rhonda Teitelbaum of Rothgerber, Appel, Powers & Johnson, Denver - (303) 623-9000

This column is prepared by the Health Law Section of the Colorado Bar Association. Lawyers representing clients in the health care industry are encouraged to submit articles to the column editor for publication. This month's article was written by Susan Fox Buchanan, Denver, executive director of the Colorado Collective for Medical Decisions, (303) 832-3002, and an associate of Buchanan and Thomas, P.C

"There is no profession from the members of which greater purity of character and a higher standard of moral excellence are required than the medical; and to attain such eminence is a duty every physician owes alike to the profession and to patients. It is due to the patients, as without it their respect and confidence cannot be commanded and to the profession, because no scientific attainments can compensate for the want of correct moral principles."

Principles of Medical Ethics of the American Medical Association
1903, Chapter II, Article I, § 5

The quickening pulse of medical ethics in the twentieth century reflects sweeping technological, economic, and political changes engulfing American medicine. By focusing on key issues of medical ethics as discussed in classic texts and contrasting them with their treatment in contemporary ethical codes, we can acquire a better understanding of present practices and deeper insight into the forces that shaped them.

BRIEF HISTORY OF CODIFIED MEDICAL ETHICS

Hippocrates the Great, or Hippocrates II, was born into the cult of Greek priest-physicians known as Asclepiads (named for Aesculapius, the god of medicine). His now-famous Hippocratic Oath, which dates to the fourth century B.C., stands as the earliest articulation of "ancient" medical ethics.1 Some 2,000 years later, the first widely recognized "contemporary" code of medical ethics emanated from England in 1803, authored by Thomas Percival (1740-1804). At its founding convention in Philadelphia in 1847, the American Medical Association ("AMA") adopted a Code of Ethics modeled on Percival's Code, making subsequent revisions in 1903, 1912, 1957, and 1980.

There are now four integrated primary sources comprising the corpus of the AMA Code of Medical Ethics ("Code"): (1) "Principles of Medical Ethics," consisting of seven imperatives introduced by a preamble; (2) "Fundamental Elements of the Patient-Physician Relationship"; (3) "Current Opinions" published annually by the AMA Council on Ethical and Judicial Affairs; and (4) periodic reports of the Council on various topics of current interest.2

PAST AND PRESENT GLIMPSES OF ETHICAL ISSUES

Truth-Telling

Honesty and full disclosure are commonly accepted as part of a physician's obligations, but this was not always the case. Hippocrates was silent on this subject, and physicians of the nineteenth century were taught to spare their patients distress and dispense emotional reassurance. Concern for the patient's emotional condition was rooted in both compassion and pragmatism. Although Freudian theories of the unconscious had not yet been formulated, Percival's Code contained harbingers of psychiatry and the recognition of psychosomatic illnesses:

The feelings and emotions of the patients under critical circumstances require to be known and to be attended to, no less than the symptoms of their diseases. . . . For though silenced by authority, they will operate secretly and forcibly on the mind, creating fear, anxiety and watchfulness."3

It quickly became apparent that efforts to avoid discouraging words sometimes collided with telling patients the truth. A section of the 1903 Code captioned "Honesty and Wisdom in Prognosis" counseled that disclosure of bad news could be "so peculiarly alarming" when delivered by a physician that it should be "assigned to another person of good judgment."4 The Code of 1912 recommended that the physician give timely notice of the patient's serious disease to the patient's friends (rather than to the patient personally), after assuring that the friends "will serve the best interests of the patient and the family."5

(It may be noted that avoidance or indirect disclosure of bad news, while antique to mainstream American medicine, is still preferred in many other cultures. Surveys and medical literature reflecting practices and beliefs within Mexican-American, Korean, Native American and other ethnic groups reflect strong traditions and enduring preferences for avoiding overt disclosure of life-threatening illness, and for regarding families, rather than patients, as primary decision-makers.6)

The uneasy balance between protecting patients and informing them is illustrated by advice of the American College of Physicians: "The physician should heed cues from the patient in setting the pace of disclosure, particularly when the illness is great. . . . Disclosure should never be a mechanical or perfunctory process. Distressing news and information should be presented to the patient in a way that minimizes despair."7 The AMA's version is somewhat more stark: "It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. Patients have the right to know their past and present medical status and to be free of any mistakes and beliefs concerning their condition."8

Confidentiality

As a corollary to full and open disclosure to their patients physicians are sworn to absolute and complete confidentiality. By the Hippocratic Oath, classical physicians were commanded that "whatever, in connection with my professional practice or not, I see or hear in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret."9 The 1847 AMA Code echoed the caveat that "none of the privacies of...