Ethics in Surgery Historical Perspective

SPECIAL ARTICLE Ethics in Surgery Historical Perspective Thomas Tung, MD; Claude H. Organ, Jr, MD thics codes and guidelines date back to the origins of medicine in virtually all civiliza- tions. Developed by the medical practitioners of each era and culture, oaths, prayers, and codes bound new physicians to the profession through agreement with the principles of conduct toward patients, colleagues, and society. Although less famous than theE Hippocratic oath, the medical fraternities of ancient India, seventh-century China, and early Hebrew society each had medical oaths or codes that medical apprentices swore to on professional initiation.1 The Hippocratic oath, which graduating medical students swear to at more than 60% of US medical schools, is perhaps the most enduring medical oath of Western civilization.2,3 Other oaths commonly sworn to by new physicians include the Declaration of Geneva (a secular, updated form of the Hippocratic oath formulated by the World Medical Association, Ferney- Voltaire, France)2,4 and the Prayer of Moses Maimondes, developed by the 18th-century Jewish physician Marcus Herz.3 The American Medical Association (AMA), cence, confidentiality, and prohibition of Chicago, Ill, has made medical ethics a cen- abortion, euthanasia, and sexual rela- terpiece of its function since the release of tions with patients—remained essen- its first Code of Medical Ethics during the tially unchanged as an ethics blueprint for 1847 convention at which the group was Western medicine until the mid 20th cen- formed.1,5 The AMA was the first na- tury.7 The origins of the Hippocratic oath tional assemblage to bind its member- are obscure, although most historians agree ship to a uniform code of ethics.5 Since that the author was not the oath’s name- then, the AMA has been at the forefront sake, Hippocrates.1,7-9 The earliest ver- of ethics discussion in the United States, sion of the oath was an updated Chris- periodically updating the Code of Medi- tian version found in the Vatican library cal Ethics, and in 1997 forming its Insti- in the 10th century AD. The most com- tute of Ethics.5 monly quoted version is the “pagan” ver- Surgical organizations have tradition- sion of the oath found in a 14th-century ally had less interest in ethics discussion manuscript.6 Two prevailing theories ex- than their medical colleagues,5 as most ist regarding the origins of the oath. pragmatic and busy surgeons do not read Most historians believe the oath origi- the plethora of philosophy-based bioeth- nated from a sect of Greek physicians who ics journals, monographs, and encyclope- were followers of Pythagoras.1,6,8 The in- dias. However, surgeons are increasingly fluence of the Pythagoreans is evident in encountering bioethics issues brought the ascetic nature of the oath, with its strict about by the changing economic and tech- moral restrictions and demands for an ex- nological landscape of surgical interven- emplary moral lifestyle for physicians. The tion.6 This increased need to know has led oath prohibited surgery,1,8,10 and this was to renewed surgical interest in the discus- incongruent with the main Hippocratic sion of bioethics issues. corpus, which offered instructions on surgical cauterization, phlebotomy, thora- THE HIPPOCRATIC OATH centesis, and drainage of abscesses.10 An alternative theory regarding the origin of The ethics precepts set forth by the Hip- the Hippocratic oath postulates that the pocratic oath—beneficence, nonmalefi- oath was created by physician-priests of the cult of Asclepias in ancient Greece.9,11 From the Department of Surgery, University of California, Davis–East Bay, Oakland. This religious cult promised health to ARCH SURG/ VOL 135, JAN 2000 WWW.ARCHSURG.COM 10 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 wealthy members of Greek society at temple spas and cal duties of physicians by the clergyman Thomas Gis- served as a commitment by the priests of the temple to borne6 and lectures on the duties and qualifications of keep the therapeutic secrets among themselves.11 physicians by the Scottish physician John Gregory.12 Both theories regarding the origins of the Hippo- The major impact of Sir Thomas Percival’s work was cratic oath highlight 2 aspects common to all oaths, codes, felt in American medicine nearly 50 years after his time. and guidelines. First, an important function of the oath In the mid 1800s, repealment of medical licensing laws is the exclusion of practitioners of medicine not within as elitist and antidemocratic by state legislatures created the originating sect. The Hippocratic oath has a trade- a chaotic situation in which there was no distinguishing guild flavor evident in the allegiance that takers of the well-trained physicians from those “unworthy of associa- oath swear to their teacher, their teacher’s family, and trade tion, either by intellectual culture, or moral disci- secrets that they are taught.1,6,11 This guild aspect of the pline...totheprofession.”5 Two hundred sixty-eight phy- oath is similar to the secrecy and commitment to an ap- sicians from 22 states met in May 1847 under the leadership prentice’s teacher seen in the medical student oath of an- of Dr Nathan Davis of Philadelphia, Pa, to form the AMA. cient India, which predates the Hippocratic oath and is Davis designated 2 of his prote´ge´s, Drs John Bell and Isaac noted in the AMA 1847 Code of Ethics, which came later.1 Hays, to write a document he believed would resolve the Second, the Hippocratic oath delineates a social con- confidence crisis in American medicine.5 This 5283- tract between physicians, patients, and society, a model word document became the AMA Code of Medical Eth- emulated by future ethics codes. Most medical gradu- ics and was unanimously adopted in that first confer- ates recite the Hippocratic oath as a covenant with their ence. The Code of Medical Ethics was a watershed for community rather than as a statement of professional al- medical ethics. It was the first attempt by a national pro- legiance.2,3 fessional group to bind its members by a uniform code of The Hippocratic oath fell largely into obscurity af- ethics. In a much more concrete fashion than the Hippo- ter it was written and was not adhered to, even by the cratic oath, it set forth a contract between the profession, Hellenistic Greek physicians following Hippocrates.1 The its patients, and the public.5,6 The AMA claimed the right principles found in the oath periodically reappeared in to reinstitute licensing requirements and minimal educa- Hebrew, Muslim, and Christian medical works such as tion standards. In return, the profession promised to drive the seventh-century oath of Asaf and the modified Chris- out quacks, mercenaries, and empirics from its ranks while tian oath according to Hippocrates of the 10th century.1 recommitting to obeying the calls of the sick. The Hippo- However, the oath disappeared and was not followed for cratic principles of beneficence, nonmaleficence, and con- centuries until it gradually returned to prominence fidentiality resurfaced in the Code of Medical Ethics in com- through Byzantine Christianity.9 As the 18th and 19th bination with rules of consultation and professional centuries approached, new ethics concerns and the de- etiquette prominent in the work of Sir Thomas Percival. sire for a sworn oath for medical school graduates led to The AMA Code of Medical Ethics has undergone the return of the oath.1 multiple revisions throughout the 20th century, begin- ning in 1903, largely precipitated by pressures from within THE AMA CODE OF MEDICAL ETHICS the profession and legal restrictions placed by the fed- eral government.1,5,6 In 1957, the Code of Medical Eth- In the late 1700s, local epidemics in England caused the ics was reduced to 10 Principles of Medical Ethics, which trustees of the Manchester Infirmary to double their hos- has since become shortened to 7 principles. Much of the pital staff in response to the greater patient load, trigger- current code has been preserved from the original work ing a bitter controversy between the newcomers and the of Drs Hays and Bell,5 but the configuration has changed established, presumably better-qualified staff mem- to a 4-part document containing the 7 Principles of Medi- bers.1-6 In 1791, Sir Thomas Percival was designated by cal Ethics; a fundamental statement regarding the patient- the trustees to write a document reviewing regulations physician relationship; opinions of the AMA’s Council for proper etiquette and conduct between staff mem- on Ethical and Judicial Affairs (CEJA) addressing newly bers at the infirmary. He followed his initial work, Of Pro- encountered bioethics issues such as human experimen- fessional Conduct Relative to Hospitals, with a treatise writ- tation, family violence, and managed care2; and reports ten in 1803 titled Medical Ethics: A Code of Institutes and explaining the rationales behind the opinions.1,5 The AMA Precepts Adapted to the Professional Conduct of Physi- remains on the forefront of bioethics discussions in the cians and Surgeons.6 The focus of these works were rules United States through the recent establishment of its In- designed to foster amiable and harmonious relations be- stitute of Ethics, whose stated mission is “to provide a tween physicians, but Percival’s writings also provided forum for timely exploration and discussion of the tough guidelines for physician behavior toward patients.6 Ac- decisions now affecting physicians and their patients.”6 cording to Percival, physicians should “unite tender- ness with steadiness and condescension with authority, A HIPPOCRATIC OATH FOR THE 20TH CENTURY as to inspire the minds of their patients with gratitude, respect, and confidence.”6 Half a century later, these words At the conclusion of World War II, the World Medical appeared verbatim in the first AMA Code of Medical Eth- Association (WMA) became interested in modernizing ics.

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