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, beginning 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. Percival’s work ended a period of quiescence in medi- the Hippocratic oath.4 During the next 50 years, the in- cal ethics extending from ancient Greece through the ternational organization published 8 separate declara- Middle Ages.1,6,12 However, his work drew heavily from tions of ethics, beginning with the Declaration of Geneva others, including the writings on patient-oriented ethi- and the International Code of Medical Ethics in 1948.4

ARCH SURG/ VOL 135, JAN 2000 WWW.ARCHSURG.COM 11

©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 The Declaration of Geneva, often recited at medical school Hippocratic oath forbade surgery.1,15,16 Whether this pro- graduation ceremonies, reiterates Hippocratic prin- hibition actually outlawed surgery or simply relegated ciples of beneficence and confidentiality with emphasis the discipline to specialists is not clear. As mentioned ear- on devotion to patient interests while abstaining from the lier, the Hippocratic corpus described numerous surgi- profit motive and treating colleagues with professional- cal procedures. However, the Hippocratic oath was not ism.2,4 At later conferences of the WMA, modern issues composed by followers of Hippocrates. As interest re- ranging from human experimentation, abortion, trans- newed in medical ethics with the formation of the AMA plantation, and human torture to psychiatric care, pa- in 1847, surgeons were once again excluded. The AMA tient autonomy, and end-of-life care were addressed by Code of Medical Ethics criticized all physicians claim- various declarations.4 ing special abilities and labeled them as quacks. The Of particular interest, the Declaration of Helsinki in American College of Surgeons (ACS), Chicago, Ill, was 1964 reemphasized the principle of informed consent for formed in 1913, and the Fellowship Pledge of the ACS volunteers in biomedical research. This issue had been is one of the earliest surgical ethics guidelines. Each ini- addressed earlier during the trial of Nazi doctors who had tiate of the college affirms the pledge by signing a state- experimented with Jewish prisoners in concentration ment on the application and reciting it during the ini- camps during World War II. At this trial, the Hippo- tiation ceremony. The pledge promises to place the welfare cratic oath was cited as the guiding ethics principle in and rights of the patient above all else. It also instructs medicine by witnesses of the prosecution.13 After con- its initiates to avoid overcharging and fee splitting. At its viction of the Nazi physicians, the tribunal put forth 10 formation, the ACS also established a central judiciary principles relevant to human experimentation, known as committee to deal with reports of misconduct by its fel- the Nuremberg Code. The Nuremberg Code included the lows. In 1994, the ACS compiled an 18-page booklet sum- concepts of informed consent, societal good, and volun- marizing a statement of principles, which covers prin- teerism as the foundation for biomedical research.13 ciples of patient care, qualifications for surgical privileges, Although designed as a secular, modernized ver- and qualifications for fellowship.6 In response to the re- sion of the Hippocratic oath, the Declaration of Geneva surgence of interest in bioethics caused by new tech- and subsequent declarations by the WMA lacked a body nologies, economic pressures, and emphasis on patient to enforce the principles set forth. Most national profes- rights, the Journal of the American College of Surgeons has sional medical groups did not endorse the WMA, and the featured an essay on bioethics since 1998. British Medical Society in London, England, actually with- The Royal Australasian College of Surgeons pub- drew from the WMA.1 In the 1960s and 1970s, paternal- lished a Code of Ethics in 1993.17 This Code of Ethics ism, a long-held basis for the relationship between phy- was provoked by the same issues that have led to a more sician and patient, began to come under attack. Ethics visible surgical presence of bioethics in America, namely codes emphasizing paternalism such as the Hippocratic patient autonomy, financial constraints on treatment ac- oath and the AMA Code of Medical Ethics were re- cess, expectations of improved outcomes, and rapid flow placed or amended by ethics guidelines emphasizing pa- of high technology.18 The Royal Australasian College Code tient rights and autonomy.7 These guidelines included of Ethics has 4 sections: a preamble, the surgeon and the the 4-principle approach to bioethics taught at the patient, the surgeon and the profession, and the sur- Kennedy Institute of Ethics, Washington, DC, the Dec- geon and society. Principles in this code include benefi- laration of Lisbon in 1981 by the WMA, and the Pa- cence, autonomy, informed consent, confidentiality, cor- tient’s Bill of Rights by the American Hospital Associa- dial dealings with colleagues, and importance of working tion, Chicago, Ill, in 1972.1,4,7 These documents for the for the good of society.18 Like the Fellowship Pledge of first time discussed full disclosure of diagnosis, progno- the ACS, the Code of Ethics provides a standard of ethi- sis, and treatment options and the patient’s right to refuse cal behavior expected from fellows of the Royal Austra- treatment. In addition to new attitudes toward patient’s lasian College of Surgeons. rights, ethics guidelines have experienced pressures from In 1986, the College of Medicine of South Africa the new economic realities of medicine. Many practi- adopted the college credo: the college (1) is committed tioners today question whether an unfaltering devotion to the maintenance of the highest professional and eth- to individual patient interest can be maintained when lim- ics standards through the primary roles as an education ited financial resources create serious health conse- and postgraduate examining body; (2) is opposed to all quences for a larger group of patients as well as mon- forms of discrimination on the grounds of race, reli- etary consequences for physicians.14 Some questioned if gion, or sex, and believes that such discrimination is in- a population-based system of ethics should be adopted compatible with the ethical practice of medicine; (3) is instead of the Hippocratic oath.14 The heightened pres- committed to striving for the improvement of the health sures from limited health care dollars, new awareness of of all the people of South Africa; advocates a unitary health patient rights, and burgeoning new technologies have led service organization supported by an open university to the reevaluation of the traditional Hippocratic oath and policy in a nondiscriminatory society, which encour- brought surgeons into bioethics discussion.6 ages equitable and fair access to education, health, rec- reational and other social services; and energetically pur- ETHICS AND SURGERY sues its policy of making available to neighboring territories and other states in Africa its multidisci- The major oaths, codes, and guidelines regarding medi- plinary educational resources; (4) strongly endorses in- cal ethics have not come from surgical organizations. The ternationally recognized human rights standards as set

ARCH SURG/ VOL 135, JAN 2000 WWW.ARCHSURG.COM 12

©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 centuries as renewed interest in medical ethics culmi- Milestones in Professional Oaths and Codes nated in the work of Sir Thomas Percival and the AMA Code of Medical Ethics. Surgeons were not involved in Ethical Code Author Date the Hippocratic oath or the guidelines of the AMA that Hippocratic oath Pythagoreans or 4th Century BC followed. The earliest ethics composition by surgeons was Asclepiads the ACS Fellowship Pledge. As the landscape of medi- Medical Ethics Sir Thomas Percival 1803 cine changed, new demands placed on physicians through American Medical Drs John Bell and 1847 Association’s Code of Isaac Hays patient autonomy, managed care, and rapidly develop- Medical Ethics ing technologies have eroded and altered the long- American College of Dr Miles F. Porter 1913 practiced ethics concepts from the Hippocratic oath and Surgeons Fellowship AMA Code of Medical Ethics. These new forces have pledge caused surgeons to seek greater visibility and responsi- Declaration of Geneva World Medical Association 1947 Nuremberg Code War Crimes Tribunal 1947 bility in discussing and deciding bioethics issues, as evi- Declaration of Helsinki World Medical Association 1964 denced by the Code of Ethics from the Royal Australa- Royal Australasian College Royal Australasian College 1993 sian College of Surgeons and the newly established essays of Surgeons Code of of Surgeons on bioethics in the Journal of the American College of Ethics Surgeons.

Corresponding author: Claude H. Organ Jr, MD, FACS, De- out in the 1975 Declaration of Tokyo, deplores torture, partment of Surgery, 1411 E 31st St, Oakland, CA 94602. and strongly condemns the involvement of medical practitioners in such practices; recommends that the medical care of prisoners and detainees should be constantly REFERENCES under review to ensure optimum care; and believes that it is of the utmost importance that their rights should be 1. Reich WT, ed. Encyclopedia of Bioethics. New York, NY: Macmillan Publishing clearly stated and enforced; and (5) condemns all forms Co Inc; 1995:2605-2630. 2. Crawshaw R, Link C. Evolution of form and circumstance in medical oaths. West of violence and is committed to the development of a just J Med. 1996;164:452-456. and peaceful society. 3. Dickstein E, Erlen J. Ethical principles contained in currently professed medical The United Nations Declaration of Human Rights oaths. Acad Med. 1991;66:622-624. was adopted on December 10, 1948, by the General As- 4. Gillon R. Medical oaths, declarations and codes. BMJ. 1985;290:1194-1195. sembly of the United Nations (without dissent) at 3 AM. 5. Baker R, Caplan A, Emanuel LL, Latham SR. Crisis, ethics, and the American Medi- cal Association 1847 and 1997. JAMA. 1997;278:163-164. The preamble of the declaration states that “whereas rec- 6. Hanlon CR. Ethics in surgery. J Am Coll Surg. 1998;186:41-49. ognition of the inherent dignity and of the equal and in- 7. Pellegrino ED. The metamorphosis of medical ethics: a 30-year retrospective. alienable rights of all members of the human family is JAMA. 1993;269:1158-1162. the foundation of freedom, justice and peace in the 8. Pellegrino ED. Ethics. JAMA. 1996;275:1807-1809. world.”19 The declaration proceeds to outline 30 articles 9. Marketos SG, Diamandopoulos AA, Bartsocas CS, Poulakou-Rebelakou E, Koutras DA. The hippocratic oath. Lancet. 1996;347:101-102. that define a clear and common understanding of these 10. Bloom DA. Hippocrates and urology: the first surgical subspecialty. Urology. 1997; rights and freedoms, which are important to the realiza- 50:157-158. tion of this pledge. This universal declaration of human 11. Robin ED, McCauley RF. Cultural lag and the hippocratic oath. Lancet. 1995;345: rights begins with article 1: All human beings are born 1422-1424. 12. Jonsen AR, reviewer. N Engl J Med. 1998;339:1792. Review of: McCullough LB. free and equal in dignity and rights. They are endowed John Gregory and the Invention of Professional Medical Ethics and the Profes- with reason and conscience that should act towards one sion of Medicine. another in the spirit of brotherhood.19 13. Shuster E. The Nuremberg Code: hippocratic ethics and human rights. Lancet. 1998;351:974-977. CONCLUSIONS 14. Kassirer JP. Managing care: should we adopt a new ethic? N Engl J Med. 1998; 339:397-398. 15. Blume E. Hippocratic oath versus managed care: physicians caught in ethical Oaths, codes, and guidelines for the ethical practice of squeeze. J Natl Cancer Inst. 1997;89:543-545. medicine date back to the Hippocratic oath of the 4th cen- 16. Patterson RH. A code of ethics. J Neurosurg. 1986;65:271-277. tury BC (Table). This oath of vague origin was largely 17. Royal Australasian College of Surgeons. Code of Ethics: September 1993. Arch forgotten at the time of its composition, but gradually Surg. 1996;131:900-901. 18. Fearnside MA. Code of ethics for the college. AustNZJSurg. 1994;64:226. assumed a place of prominence through its influence on 19. The Writing Group for the Consortium for Health and Human Rights. Health and Christian, Muslim, and Hebrew medical works in the human rights: a call to action on the 50th anniversary of the universal declara- Middle Ages. It gradually reappeared in the 18th and 19th tion of human rights. JAMA. 1998;280:462-464, 469-470.

ARCH SURG/ VOL 135, JAN 2000 WWW.ARCHSURG.COM 13