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​Medical Ethics – Then and Now

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                                                            By Michael A. Kalm, M.D.
            The year 1847 marked two game-changing events.  In one, pioneers under the leadership of Brigham Young entered the Salt Lake Valley to establish a homeland.  It is said that when Brigham Young first saw the valley from what would be known as Emigration Canyon, he said, “This is the right place.”
            The other event of 1847 was the founding of the American Medical Association. At the founding meeting, the new organization adopted the world’s very first national “Code of Medical Ethics,” which was published later that year.  The two events are connected not only by time, but by subject, for what is “ethics” other than that which is “right”?  Ethics is the branch of philosophy that deals with moral principles, distinguishing between right and wrong, good and evil.
            In 1847, 250 delegates from 28 states met in Philadelphia to form the AMA.  Part of the impetus of this meeting was the awareness of the delegates of the “dangers of universal traffic in quack remedies and nostrums.”  The fledgling AMA wanted to establish standards for Medical education, training and conduct to enlighten the public and counteract this dangerous trend.  The first published edition of the code ran to 26 pages, eight pages of which were thoughtful introduction.  The code was revised in 1903 to a total length of seven pages, revised again in 1957 to a total length of three pages, and one more time in 1980, to one page.  Lest you think that the code was being successively dumbed down and cannibalized, be aware that the current code of medical ethics, with annotations, runs to 511 pages!  Why all these revisions?  Isn’t right and wrong something obvious? – something immutable?  No.  These revisions were all warranted by conditions arising that could not have been even dreamed of in 1847.  These revisions also reflect changes in social and cultural mores that also were unlikely to have been conceived of in 1847.  No matter how absolute they sound, “right” and “wrong” are not static concepts carved into stone.
            In the 1847 version, the very first sentence reads, “Medical ethics as a branch of general ethics, must rest on the basis of religion and morality.”  This emphasis on religion has been removed from recent revisions.  Another interesting statement in that first code of Medical ethics that was absent from later revisions was, “As it is the duty of a physician to advise, so has he a right to be attentively and respectfully listened to.”  Perhaps physicians of the 20th Century realized that expecting to be listened to was asking too much!
            The authors in 1847 were well aware of the choice the public had between “the directness and sincerity of purpose, the honest zeal, the learning and impartial observations, of the regularly initiated members of the medical profession, and the crooked devices and low arts, for evidently selfish ends, the unsupported promises and reckless trials of interloping empirics, whose very announcements of the means by which they profess to perform their wonders are, for the most part, misleading and false.”  I have to admire the perspicacity of these early physicians in anticipating TV doctors 100 years before the invention of TV.  The authors were also concerned about the gullibility of the public: “These delusions are sometimes manifested in the guise of a new and infallible system of medical practice, - the faith in which, among the excited believers, is usually in the inverse ratio of the amount of common sense evidence in its favor. “
            In 1847, the authors spent considerable time on obligations of patients and the public to their physicians as well as physicians’ obligations to their patients and the public.  Today’s code has removed that obligation FROM patients and the public.  Today’s code clarifies physicians’ obligations, not only to our patients, but also to society, to other health professionals, and to self.  
            It is charming to note that in 1847, most of the descriptions of obligations revolved around the physician’s visit to the home of his patients.  Those days of home visits are long gone, but what should perhaps not be long gone are other principles of medicine described in that code.  For example, the code encourages patients to confide care for himself and his family “as much as possible to one physician, for a medical man who has become acquainted with the peculiarities of constitution, habits, and predispositions, of those he attends, is more likely to be successful in his treatment, than one who does not possess that knowledge.”  Not only do we rarely avail ourselves of this sage wisdom in our multi-specialtied, high-tech, 10 minute appointment world, I know some Psychiatrists who are reluctant to see more than one member of a family for fear of being biased toward one member of the family at the expense of another.  And while we are on the subject of Psychiatry, the 1847 authors state that “Patients should, faithfully and unreservedly communicate to their physician the supposed cause of their disease. This is the more important, as many diseases of a mental origin simulate those depending on external causes, and yet are only to be cured by ministering to the mind diseased.  A patient should never be afraid of thus making his physician his friend and adviser; however commendable a modest reserve may be in the common occurrences of life, its strict observance in medicine is often attended with the most serious consequences.”
            It is also quaint, or perhaps poignant to note that in 1847, prohibition of advertising by physicians, and professional courtesy for all physicians were the norms.
            In the current code, there is a brief mention that “a physician shall… obtain consultation.  In 1847 there were 21 separate nuanced paragraphs dealing with every aspect of consultation and possible interference between physicians.  I leave it to more able historians to explain why that was so important in 1847 and has lost importance now.
            The most recent revision of the AMA’s Code of Medical Ethics is clearly stated on one page in the form of nine concise ethical principles.  Some of them are no-brainers, some are subject to opinion and argument, and some are – missing.  I’ll list a no-brainer first: “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.”  Nothing gray about that, and I would hope all physicians would agree to that without hesitation.  But how about “A physician shall…  strive to report physicians deficient in character or competence,”? As Atul Gawande pointed out in his book, Complications, reporting a fellow physician “deficient in character or competence,” is something most physicians strive to avoid.  It is fraught with too much emotional difficulty and physicians will follow the path of denial as long as they can, before one courageous physician has the fortitude to take the erring physician aside for a “Terribly Quiet Chat.”
            And then there is what is missing.  1957’s version of the Code of Medical Ethics, had the following: “A physician should not dispose of his services under terms or conditions which tend to interfere with or impair the free and complete exercise of his medical judgment and skill or tend to cause a deterioration of the quality of medical care.”  This is not to be found in the current code.  And no wonder.  With new high tech treatments that have been priced beyond the reach of what many people can afford, or what many insurance companies will approve, doctors find themselves more and more constrained from exercising their “complete exercise of medical judgment.”  And I am not trying to paint insurance companies as villains here.  It is simply a fact that we struggle to acknowledge, that more superb treatment exists than we as a nation can afford.
Finally, what are some of the new things, that make up the bulk of the 511 page book of “The Code of Medical Ethics,” plus numerous supplemental articles since, new things that would not have been dreamed of in 1847 or even 1957?  Here is a list of some of the new ethical guidelines that have been included: 
1.Physician obligation in disaster preparedness and response. 
2.Physician participation in interrogations, genetic testing and counseling. 
3.Financial relationships with industry in Continuing Medical Education. 
4.Advance care planning. 
5.Professionalism in the use of social media. 
6.Research with stem cells (replaces Cloning for Biomedical Research).
7.Transplantation of organs from living donors.
In addition to guidelines, the current Code of Medical Ethics contains many articles where ethical issues are still under discussion – where there has not yet been a consensus of opinion to conclude with a formal guideline.  Here is a sample of some of the recent AMA News articles on Medical Ethics: 
1.“What authority does a caregiver have for an incapacitated patient? For the first time, a health care organization details how its physicians help terminally ill patients navigate the process of securing lethal prescriptions.” 
2.“Whether mandating influenza immunizations is appropriate.”  
3.“North Dakota has enacted the earliest abortion ban in the nation, among other measures restricting the availability of the procedure.”  
4.“Efforts to exhaust all treatment options before transitioning to palliative care may deprive patients of the full range of hospice services, says a JAMA study.”
Samuel Johnson famously said, "The fact of twilight does not mean you cannot tell day from night."  Johnson was right, but that doesn’t mean the task is easy.  Just as the evolution of Science itself teaches us that the more knowledge we gain, the more questions we have unanswered, the evolution of Medical Ethics over the past 165 years teaches us that we must strive to increase our awareness, continually question, continually explore options.  We will never have a “carved in stone” right or wrong that applies to everyone in every situation, but we will increase our understanding into the most important underpinnings of our profession.
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