The 1847 Code of Medical Ethics

The First Ethical Code Adopted by the American Medical Association

Sep 6, 2009 Jeffrey Willett

Although medicine had been practiced in the United States for hundreds of years, the first Code of Medical Ethics for physicians was not written until 1847.

Medicine is an ancient art that has long struggled to balance the interests of the patient against the self-interest of the physician. The original Oath of Hippocrates required doctors to use their best judgment in following a “system of regimen . . . for the benefit of my patients,” while also refraining from “whatever is deleterious & mischievous.” Yet the Oath does not recognize the right of a patient to give consent before treatment, nor does it stop doctors from acting improperly. Centuries would pass before medicine was accepted as a profession that needed its own code of ethics.

Oaths, Codes, and Ethics

Since ancient times, medicine lacked a system of regulation from within. Physicians subscribed to the Oath of Hippocrates upon being admitted to practice, but an oath is a promise to behave in a certain way, not a standard of conduct with clear consequences for transgressors. As Davis (1999) observed, the origins of the word 'code' can be traced back to Emperor Justinian I. Between 529 AD and 534 AD, Justinian I issued a series of royal pronouncements (the Corpus Juris Civilis) as a code. The resulting civil code differed from other pronouncements because it was enacted into law and could be enforced through the Roman courts.

Being subject to civil law, however, is not the same thing as having an internal standard of conduct. In its conventional sense, 'ethics' refers to a system of beliefs based on moral (but not necessarily legal) authority. In this sense, while physicians may have been subject to local civil codes, ethics was a matter of individual preference.

Medical Ethicists Argue for Professionalism

McCullough (2004) notes that the first medical ethicists were John Gregory (1724–1773) and Thomas Percival (1740–1804). During the 1760s, both men argued that medical practitioners should consider themselves as 'professionals,' although the reason for doing so probably had little to do with ethics. At that time, physicians were trying to encourage well-to-do patients to seek and pay for their services rather than those of practitioners without formal medical training. The name 'professional,' thus, referred to a person who was part of a special profession that merited more respect than 'quacks' who sold ineffective remedies.

Unfortunately, physicians who saw themselves as professionals also felt that they were gentlemen who did not need regulation. In the absence of formal professional societies, physicians followed their own informal guidelines. Such guidelines often led to objectionable practices, as when surgeons belonging to the Manchester Infirmary went on strike in 1792 and turned away patients during a typhus epidemic.

In response, Thomas Percival drafted the first set of practical guidelines for physicians in 1794. Nine years later, Percival expanded his guidelines into a book entitled, Medical Ethics; or, A Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons. In order for physicians to be considered professionals, Percival argued that they should be competent in medicine, follow a system that relied on scientific evidence, and assume a fiduciary relationship with patients.

The American Medical Association is Formed

Percival recognized that physicians needed to adhere to conduct that was beyond what was set out in law. Yet, Percival did not write a code of professional ethics; he was a single physician and not an organization with authority to speak for all its members.

A copy of Percival's Medical Ethics crossed the Atlantic Ocean and inspired the Boston Medical Society to adopt a simple code of ethics in 1808. The code adopted, however, was limited because it relied on individual honor and applied only to practitioners in the Boston area.

In 1847, the American Medical Association (AMA) was formed in Philadelphia. Later that year, the AMA published its Code of Medical Ethics, which borrowed liberally from Percival’s work. For the first time anywhere, a national professional organization created a set of guidelines for its members.

The AMA Code of Medical Ethics

The original AMA Code of Medical Ethics was an important first step, but sometimes one where the old relationship of mutual respect and trust between physician and patient was ignored. In 1847, physicians were advised variously to stay away from the sick, keep bad news from the ill, require strict obedience from the patient, and — above all — never dispense advice or treatment to the poor for free.

Although the AMA acknowledged that medical ethics was based on morality, the Code did not adopt any of Percival’s cautions regarding human experimentation. Instead, it seemed more concerned with denouncing quackery: “By an anomaly of legislation . . . the laws . . . are silent . . . in the cases of both fraud and poisoning so extensively carried on by the host of quacks who infest the land.” The Code also stressed the rights of a physician in society “to prevent needlessly harassing calls on his services and unnecessary exhaustion of his benevolent sympathies.”

The 1847 AMA Code was 16 pages in length; the recent 2008–2009 edition is 504 pages. Although ethical issues in medicine have grown more complex over time, the professional duties owed by a physician to a patient (as set forth by Thomas Percival and the AMA) still resonate today.

References

American Medical Association. 1847. Code of Medical Ethics of the American Medical Association. Chicago: American Medical Association Press.

Davis M. 1999. Writing a code of ethics. Perspectives on the Professions. 19(1):2–4.

McCullough LB. 2004. The nature and limits of the physician’s professional responsibilities: surgical ethics, matters of conscience, and managed care. Journal of Medicine and Philosophy. 29(1):3–9.

The copyright of the article The 1847 Code of Medical Ethics in Biology is owned by Jeffrey Willett. Permission to republish The 1847 Code of Medical Ethics in print or online must be granted by the author in writing.

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