" Honour and Interests": Medical Ethics in Britain, and the Work of The
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Thesis C53ÎO “Honour and interests”: medical ethics in Britain, and the work of the British Medical Association’s Central Ethical Committee, 1902 - 1939 0 3 8 0 submitted by Dr. Andrew Alexander George Morrice BSc MB BS for the degree of MD University of London January 1999 The copyright of this thesis rests with the author and no quotation from it or information derived from it may be published without the prior consent of the author ProQuest Number: 10015040 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest. ProQuest 10015040 Published by ProQuest LLC(2016). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. Microform Edition © ProQuest LLC. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 Abstract: Histories of medical ethics have neglected the early twentieth century, and concentrated on philosophical principles, codes, current concerns, or have described older ethical systems as etiquette, designed to enrich doctors. I have examined the Central Ethical Committee (CEC) of the BMA, an organisation then representing most practising doctors, and analysed medical ethics as a social historical phenomenon and aspect of medical professionalisation. In 1902 the new BMA and CEC emerged from a medico-political crisis in which failures of solidarity were construed as ethical issues. The key members of the CEC were senior middle- ranking practitioners, but the organisation had strong links with the General Medical Council and the Medical Defence Union. The committee dealt largely with enquiries and disputes between doctors, but also formulated policy on medical ethics, considering all the issues prominent in the sparse contemporary literature. These issues have been examined in turn, along with the literature starting with Percival’s 1803 Code, and the behavioural strictures inherent in collegiate organisations. These issues were, solidarity in boycotting unsuitable appointments; the use of local ‘courts of honour’ to settle disputes; the etiquette and ethics of consultation; relationships with unqualified and unorthodox practitioners; advertising that both directly and indirectly involved doctors; relationships with medical businesses of all kinds; and confidentiality, particularly in courts of law. Abortion is discussed as an example of a moral question not then included in medical ethics per se. This system aimed to uphold unwritten medical characteristics and traditions, to differentiate doctors from quacks and tradesmen, and to promote professional honour, as a means of defending medical interests. It defined the profession behaviourally, and created a ‘space’ in which medical excellence could flourish. Despite profound social and technological change medical ethics can still be construed as a moral adjudication of medical behaviour integral to defining the boundaries between profession, patients and society. Acknowledgements Christopher Lawrence, my tutor in 1987 - 88, did me two great favours, firstly by directing my interest in history of diet toward the specific example of Sir William Arbuthnot Lane, and secondly through his rigorous approach to the writing of history, some of which, I hope, has remained with me. He and Tilli Tansey sponsored my Research Fellowships in 1992 - 93 during which time I started some of the research on which this thesis is based. I must thank the Wellcome Trust for their support funding my research fellowships at the Wellcome Institute for the History of Medicine. In the periods of time between my years at the Wellcome Institute, during which I was a clinical student, and later working as a Junior Hospital Doctor and GP trainee, the personal and intellectual encouragement of Michael Neve has been indispensable. Roy Porter encouraged me to examine the ethical material in the BMA archive thoroughly. Bill Bynum, who need not have taken me on as a student during his sabbatical, deserves unreserved thanks for the generosity with which he has made his time available to me, and for the pertinent advice he has always offered. My archival tasks would have been intolerable but for the help and support of Emily Naish, archivist at BMA House, and Lesley Hall and Julia Sheppard at the Wellcome Contemporary Medical Archives Centre. The Library staff at the Royal Society of Medicine also helped on many occasions, especially when I was lost in their basement stacks. Comments, criticism and support have over the years been welcome from many colleagues, but I should like to mention particularly some not already mentioned, they include: Anne Hardy, Mark Harrison, John Carson, Stephen Lock, J Stuart Homer, Rhodri Hayward, Chandak Sengoopta. Lastly, I have come to discover why theses and books are so often dedicated to the partner of the author. My wife Jane has put up with this project, and the impact it has had on our home life, with great cheerfulness. And my son Angus, who has not the first clue what I have been doing up in our attic all this time, has, with his mother, provided the perfect antidote to the life of the scholar. “In a book of this kind the accident of where and when the author was educated is bound to make a difference, both to the selection and the treatment of the material.... It may be thought that in some cases too long has been spent on the details of a rather trivial argument, at the expense of a wider view of the whole subject. My defence would be that in such a subject as ethics, the details of the argument are all important. ... I have not, I hope had any preconceived idea of what ethics is.” Wamock, Mary, Ethics since 1900, (2nd ed.), London, Oxford University Press, 1966, preface. Table of contents Section 1 -The CEC in historical and organisational context Chapter 1 13 Introduction 13 The history and histories of medical ethics 15 The Enlightenment 17 The nineteenth and twentieth centuries 19 The work leading up to the current research 20 J Stuart Homer’s thesis 21 Research materials and methods 23 General Ethics - the “missing factor” 24 Chronology 25 Thesis Outline 26 Technical points 27 Glossary of special terms 28 Abbreviations 28 Chapter 2 The BMA and medical ethics. 1832 - 1902 29 Introduction 29 The early BMA and Medical Ethics 29 Founding ideals 29 The early history of the BMA 31 The early BMA and medical ethics 33 Contract practice 35 Background information 35 Ostracism in contract practice disputes 37 Professional bodies and contract practice 39 Medical Ethics and the BMA in the 1890s 40 The General Practice and Ethics Committee 42 New BMA: new “fighting machinery” 43 Chapter 3 The Central Ethical Committee and the BMA after 1902 45 The New BMA 45 The functions and constitution of the CEC 46 Pattern of CEC work 47 Membership and Chairmanship 48 The core of long-serving members 49 Prosopography of members serving 5 years or more 50 Chairmen of the CEC 53 Other personnel 55 The CEC in the context of the BMA 55 Presenting a problem to the CEC 55 Communicating the decisions and opinions of the CEC 56 Resisting codification 56 Summary 59 Chapter 4 The CEC in context: other organisations____________________________________________ 60 Introduction 60 The Royal College of Physicians of London 61 The origins and development of the College 61 The disciplinary functions of the College 61 The Composition of the Censors Board 1902 - 1939 63 The Royal College of Surgeons of England 64 The General Medical Council 65 The constitution of the CMC and the Medical Acts 65 The development of the CMC as a disciplinary body 68 Contemporary criticisms of the CMC 70 The Warning Notices 71 The CMC and the BMA 73 The BMA’s Direct Representative scheme 74 The BMA as complainant to the CMC 78 The Medical Defence Union 83 The MDU and the CMC 85 The MDU and the BMA 86 Discussion 87 Chapter 5 The CEC in context; the contemporary literature_____________________________________ 89 Introduction 89 Three “greats” 90 Jukes de Styrap,A Code o f medical ethics 90 Robert Saundby, Medical ethics 92 Aitchison Robertson, Medical Conduct and Practice 94 Voices from the past 95 W H S Jones, The Doctor's Oath 95 Chancey D Leake, Percival’s Medical Ethics, and its reception 96 C O Hawthorne on Medical Ethics in Practitioner, 1936. 97 5 Guidance in Practice 97 BMA Handbooks for Medical Practitioners 97 The GMC Warning Notices 99 Squire Sprigge et al,The conduct of medical practice 100 The medico-legal literature 101 Medical jurisprudence texts 101 The medico-legal literature 102 The Medico-legal society 102 Discussion 103 Section II - The Ethical Issues Chapter 6 The Ethics of Appointments and the general Ethical Rules _____________________________ 105 Introduction The “Bradford Rules”: a contract practice boycott scheme 105 Roots in professional culture and local medical opinion 106 A task for the new BMA 108 The “Bradford Rules” on appointments (1905) 109 The BMJ Warning Notice 111 The Investigation into Contract Practice, 1903 - 5 112 Operating the boycott scheme and early changes 113 The Hampstead Hospital Dispute 1905 - 1910 114 The Rules, the Notice and the threat of litigation 119 Initial changes to the Notice 1910-1914 119 The Bedford libel case: 1908 - 1913. 120 The general Ethical Rules, up